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Full text of "The Royal London Ophthalmic Hospital reports"

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Ophthalmic Hospital 
Reports. 



1897. 



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VOLUME FOUKTEEN, 

LONDON: M 

J & A. CHURCHILL, 7, GREAT MARLBOROUGH STREET. 



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LONDON : 

HARRISON AND SONS, PRINTERS IN ORDINARY TO HER MAJESTY, 

ST. martin's LANE. 



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CONTENTS 



THE FOURTEENTH VOLUME 



Part I. 

PACK 

1. E. Treacher Collins, Descriptive Catalogue of Specimens. in the 

Hospital Museum {continued). (Illustrated) 1 

2. C. Deverettx Marshall, On the Immediate and Remote Results 

of Cataract Extraction ;..... »0 

3. "W. T. Holmes Spicer, Contracture and other Conditions following 

Paralysis of Ocular Muscles ■• • ■ 22 ° 

4. N. C. Ridley, Serous Cyclitis. (Illustrated) 237 

5. W. Tilling-hast Atwool, Two Cases of Hereditary Congenital 

' -Night-Blindness. (Illustrated) ■....- ■• • • -260 

6. N.-C. Ridley, Notes on a Case of Thrombosis of the Central Artery 

of the Retina, with Acute Glaucoma as a Sequel. (Illustrated) . . 264 

7. H. Y. McKrnzie, On the Results obtained after the Extraction of 

Foreign Bodies from the Eye with the Electro-Magnet 274 



Part II. 

8. J. Herbert Fisher, A Case of Subhyaloid Hemorrhage, in which the 

Specimen was obtained with Microscopic Sections. (Illustrated) 291 

0. E. Treacher Collins, The Development of the Posterior Elastic 

Lamina of the Cornea or Membrane of Descemet. (Illustrated). . 305 

10. C. DeyereTjx Marshall, On Meningitis following Excision of the 

Eyeball for Panophthalmitis . , 312 

11. W. T. Holmes SpiceR, Striated Opacity of the Cornea. (Illustrated) 338 
12 Andrew Hallidie, Topography of the Emmetropic Fundus. (Illus- 
trated). , 301 



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IV CONTENTS 

PAGE 

13.. E. Treacher Collins, Case of Permanent Central Scotoma caused 

by looking at the San, with Partial Atrophy of the Optic Nerve . . 374 

14. C. Deyereux Marshall, On the Pathological Examination of the 

Eyeball. (Illustrated) . - 379 

15. A. H. Thompson, Tobacco Amblyopia: some cases in which the 

interval between Cessation of Smoking and Improvement of Vision 

was unusually long ........ .... 405 

16. H. V. McICenzie and C. Deveheux Marshall, On Ophthalmia 

Neonatorum . . ...,...,....,,,..,... 410 



Part III. 
17. C. Deyereux Marshall, Metastatic Carcinoma of the Eyeball ..... 415 

IS. J. Herbert Fisher, Concomitant Strabismus : The Accessory Ad- 
ductors and Abductors .......... v 448 

19. C. Deyereux Marshall, Notes on.G-lioma Retinas . , . . . . . 456 

20. -E* C. Eischer and C. Devereux Marshall, The Operative Treat- 

ment of Lamellar Cataract , 478 

21. Arnold Laws on, An Historical Review and Criticism of the Bacte- 

riological History of Trachoma, with Personal Observations on 
Fifteen Cases ■ . . . ; 48 i 

22. C. Deyereux Marshall, Descriptive Catalogue of Specimens in the 

Hospital Museum (continued) , 500 

23. Supplementary Catalogue of the Library of the Royal London Oph- 

thalmic Hospital, Moorfields ; 546 

Index to Yolume XIV (Authors) 555 

„ „ (Subjects) 557 



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C6e 3&ogat Hontioit 
Ophthalmic Hospital Reports. 

Vol. XIV. Pajit L October, 1895, 



DESCRIPTIVE CATALOaUE OE SPECIMENS IN THE 
HOSPITAL MUSEUM (continued). 

By E. Treacher Collins, late Curator, 

Series IV. — Tumours. 

Subseries (A). — Starting in the Orbit, 

The orbit contains a number of structures of such widely 
different natures, that the characters of the tumours 
starting in it are very various. Those which begin in the 
eyeball or optic nerve, and only secondarily extend into 
the orbit, are not included in this section, but are placed 
under those of the tissues in which they originate. 

The cystic tumours of the orbit, hydatids and dermoids, 
are rare. Growths may arise from the lymphatic or 
vascular channels; the latter, which are pulsatile, may be 
plexiform or cavernous in structure. No specimen of any 
of the above-mentioned growths are contained in the 
museum. There is one of a primary sarcoma of the 
lacrymal gland (No. 1) ; adenomatous and carcinomatous 
tumours may also arise in it. 

Tumours originating from the bony walls of the orbit 
may be innocent or malignant, osteomata (Nos. 2 and 3) 
or osteo-sarcomata (No. 4). The osteomata are usually 
extremely hard, having an ivory consistency, and present 
microscopically the characters typical of true bone. It is 
VOL. xiv, B 



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2 DESCRIPTIVE CATALOGUE OP SPECIMENS 

very difficult sometimes to say whether they originated in 
the orbit itself or in one of the sinuses around. The 
frontal sinus is a frequent seat for them to commence in 
(No. 3). When originating in a sinus, its walls become 
expanded and are ultimately burst through by the 
gradual enlargement of the growth; in the case of the 
frontal sinus, the cerebral and orbital cavities thus 
become involved (No. 3). 

Osteomata originating on the inner wall of the orbit 
are often pedunculated, and are then more suitable for 
operation than when sessile, as the neck sometimes breaks 
through quite easily (No. 2) ; it has even been known to 
do so spontaneously. 

By far the commonest form of tumour met with in 
the orbit is sarcoma. At the stage in which the speci- 
mens are usually obtained it is difficult to locate the 
structure in which they originated. Doubtless they may 
start in any of its fibrous tissues. Those coming from the 
periosteum sometimes have small pieces of more or less 
well developed bone scattered throughout them (No. 4). 
Many of them are extremely fibrous in structure, and 
were formerly classed as malignant fibromata (Nos. 5 
and 7). The muscles surrounding the eye are often the 
seat of the growth or are secondarily involved, each 
individual muscle fibre becoming isolated by the sarcoma 
cells (No. 9). One of the earliest symptoms to which a 
tumour of the orbit gives rise is proptosis. The direction 
in which the eye is displaced varies with the position of 
the tumour; when starting near the apex of the orbit, 
the globe becomes pushed directly forwards (Nos. 6 
and 9). The nerve is often affected from pressure in such 
cases (No. 6), and sometimes the eyeball itself becomes 
flattened on one side (No. 5). 

No. 1. — A portion of a new growth removed from the orbit 
of a lad, aged 17. Some swelling of his left upper eyelid had 
been first noticed about two months previous to the removal of 



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IN THE HOSPITAL MUSEUM. 3 

the growth. There was also slight piMjptosis, which gradually 
increased. An exploratory incision revealed a tumour in the 
upper and outer part of the orbit. 

The specimen, which, is not quite half the whole growth, is 
a pinkish, firm mass, with greyish streaks running through it. 
Microscopically it is found to consist mainly of fibrous tissue, 
and cells which are mostly round; in places, gland tubules 
precisely similar to those of the lacrimal gland are seen, widely 
separated from one another by the cells and fibrous tissue of 
the growth. 

(Recorded in the RL.O.H. Reports, vol. xiii, p. 395.) 

No. 2. — A plaster cast of an osteoma which was successfully 
removed from the orbit. The history of the case is not known. 
The cast is concave on the surface, which represents that 
attached to the orbital wall ; this has been coloured blue. The 
greatest length, of the cast is 5 cm. Its free surface is nodu- 
lated and very irregular. 

3. A portion of the left frontal bone with the upper margin 
of the orbit, and a large bony tumour growing from the frontal 
sinus. The specimen was removed from a man, aged 25, who 
died from cerebral meningitis 31 days after an operation for 
the removal of an ivory exostosis of the roof of the orbit. 

His left eyeball was stated to have been prominent for two 
years, and the protrusion was steadily increasing. A large 
portion of the bony growth, was removed, after a prolonged 
operation, by means of a powerful Archimedean screw, chisels, 
and mallet. The orbit was then left about its normal size' 
and shape. The wound healed, and all went well until a 
month, after the operation, when the patient complained of 
slight pain in his head ; his temperature went up, he became 
unconscious, had some slight convulsive attacks, and died 
24 hours after the onset of these symptoms. The growth is a 
large nodulated mass of exceedingly hard bone. Its orbital 
surface, from which a portion was removed at the operation, is 
rough and irregular. On the outer surface the atrophied shell 
of the plate of the frontal bone is seen arched upwards by the 
growth which has extended a considerable way into the cranial 
cavity. About the centre of the inner surface a smooth piece 

B 2 



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4 DESCRIPTIVE CATALOGUE OF SPECIMENS 

of bone, the orbital plate of the ethmoid, remains attached to 
the growth. At the lower and posterior part of the mass is a 
smooth groove in which the optic nerve lay embedded. 
(Recorded in the R.L.O.H. Reports, vol. x, p. 303.) 

No. 4. — A tumour which was removed from the left orbit of 
a man, aged 19. It has been divided into two halves, which are 
mounted in separate cells. His left eye was first noticed to be 
prominent five years previous to the operation. The pro- 
minence afterwards extended to the eyebrow and upper lid, 
and increased rapidly during the last 18 months. His general 
health was good, and there was no history of tumours in his 
family. The tumour was removed through an incision in the 
upper lid by the help of a gouge. It was attached to the upper 
and outer wall of the orbit, and had pushed the eye downwards 
and inwards without materially affecting his visual power. 
The growth is irregularly pear-shaped, and measures 42 mm. x 
29 mm. Its weight when fresh was 6 drachms. Its surface, 
except where it was attached to the roof of the orbit, is covered 
by a white fibrous membrane. The surface of attachment is 
rough, like broken cancellated bone, and about 25 mm. wide. 
The cut surface discloses a partly calcified porous structure, 
dark red in the recent state, and the open mouths of vasculnr 
channels Gan be seen in it with the naked eye. Microscopically 
it is stated to be composed of partly ossified fibrous tissue, in 
which the vascular canals (Haversian canals) radiate from its 
base of attachment towards its surface. 

(Recorded in R.L.O.H. Reports, vol. iii, p. 80.) 

^[ 0# 5. — A large tumour and half the right eye removed from 
the orbit of a man, aged 45. They are mounted in separate 
cells. Four years previous to the operation he had first 
noticed a prominence of his right eye, which had gradually 
increased; the eye had been quite blind for 12 months. There 
was no history of any cerebral symptoms ; no family history, of 
tumours, and no glandular affection. He had had a blow on 
one of his eyes (he was not sure which) from a stone five years 
before the prominence commenced. The growth, which is about 
the size of a tennis ball, is not quite entire, a portion having 
been cut off its posterior surface. It is covered by a fibrous 



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IN THE HOSPITAL MUSEUM. D 

capsule. It is firm in consistency and, when fresh, appeared on 
section of a uniform pinkish-grey colour with a few streaks of 
yellow in it. Microscopically it is seen to consist of bundles of 
fibrous tissue and groups of closely packed spindle-shaped cells; 
many blood vessels course through it. The eyeball on the 
inner side is much flattened ; the sclerotic, instead of being 
curved, is quite straight. The retina is somewhat creased, 
otherwise the eye appears healthy. 

No. 6. — Portions of the left eye, the optic nerve and a 
tumour surrounding it, removed from the orbit of a man, 
aged 33. Five weeks previous to the operation he first 
noticed pain in his left eye, a month later he found that he 
saw double. On his Coming under observation there was found 
to be ptosis, oedema of the conjunctiva, restriction of the 
movements of the globe and proptosis. Ophthalmoscopic 
examination showed blurring of the margin of the optic disc 
and enlargement and tortuosity of the retinal veins. The 
eyeball is somewhat flattened anterio-posteriorly, otherwise it 
appears healthy; a piece of optic nerve, 23 mm. in length, 
has been removed with it, and is surrounded by the new 
growth, which is also intimately adherent to the sclerotic 
poteriorly. The growth is roughly about the size of a chesnut, 
and has been cut into in places during removal. Microscopi- 
cally the growth is seen to be a round-celled sarcoma, which 
infiltrates the structures around, but apparently does not start 
from the sheath of the optic nerve. 

No. 7. — A tumour, removed from the left orbit of a girl, 
aged 5. Proptosis of her left eye had been noticed for six weeks 
previous to the operation ; it was displaced forwards, outwards, 
and downwards, and its upward movement was much re- 
stricted. The tumour has been partly divided into two, and is 
about the size of a Brazil nut; it is firm in consistency, and its 
outer surface is nodulated. The cut surface presents a whitish, 
striated appearance, very much like that of an unripe pear. 
Microscopically the growth is seen to be a spindle-celled 
sarcoma ; in places the cells have undergone degeneration. 

The growth recurred in the orbit; a second operation was 
performed 10 months after the first, and a third six months later. 



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b DESCRIPTIVE CATALOGUE OF SPECIMENS 

No. 8. — A recurrent growth and a portion of the upper 
eyelid, removed from the left orbit of a woman, aged 60. The 
primary growth had been removed from the orbit two months 
previous to the operation for the recurrence. Prominence of 
the eye and failure of sight was noted eight months previous 
to the first operation. The tumour has been cut into pos- 
teriorly, it is of yellowish hue on section, and its several 
portions are seen sharply defined from the orbital tissue which 
they are infiltrating. Microscopically the growth is seen to be 
a spindle-celled sarcoma. 

No. 9. — The eyelids, the whole conjunctival sac, and the 
eyeball with a considerable portion of the extraocular muscles 
attached to it, all of which were removed en masse from a right 
orbit of a man, aged 69, who had ptosis, with proptosis and 
almost complete loss of all ocular movements, but without any 
fundus changes, though the sight was very defective. This 
had existed for five months. Some days after the operation, 
chloride of zinc paste was applied to the orbit. At the present 
time, nearly six years since the operation, there is no recurrence 
of the growth, ar>d the patient enjoys perfect health. The four 
recti muscles are much thickened, especially the superior. The 
thickenirg is most marked posteriorly, and lessens near their 
insertion into the globe. The optic nerve appears healthy. 
Microscopical examination of sections of the muscles show 
them to be infiltrated with numerous small round cells ; these 
-are situated between the muscle fibres, which they completely 
isolate. A sarcoma starting near the apex of the orbit has 
extended forwards along the muscles. 

Sub series (B).— Starting in the Conjunctiva or Eyelids. 

New growths of the eyelids and conjunctiva are very 
common, but usually come under treatment in an early 
stage, so that specimens of -them suitable for preservation 
in a museum are not often obtained. The only ones of 
which examples are contained in this collection are 
papillomata (No. 1) and sarcomata of the conjunctiva 
(No. 2), and horns (Nos. 3, 4, 5, and 6) and dermoid cysts 
of the eyelids (No. 7). 



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IN THE HOSPITAL MUSEUM. < 

The conjunctiva and eyelids may also be the seat of 
nsevi, cysts, fibromata, adenomata, glandular carcinomata, 
rodent ulcers, and epitheliomata. 

Papillomatous growths of the conjunctiva are very 
infrequent ; the one contained here resembles very closely 
in its structure a villous tumour of the bladder (No. 1). 

Horny growths of the eyelids, which sometimes attain 
considerable size (Nos. 3, 4, 5, and 6), commence as warts, 
whose surface epithelium becomes dry and hard, and is 
not cast off. 

Dermoid cysts in the eyelids or eyebrow, due to 
sequestration of a portion of the surface epiblast during 
foetal life, are by no means uncommon; they are most 
often met with at the outer or inner angle of the orbit, 
along the line of the orbito-nasal fissure. They are deeply 
situated beneath the orbicularis muscle and in contact 
with the pericranium. Their contents consist of sebaceous 
matter, and degenerate epithelial cells (No. 7). Their 
walls are lined on the inner surface by laminated epithe- 
lium, amongst which hairs grow. 

Sarcomata of the conjunctiva are rare ; they may be 
devoid of pigment'or densely black (No. 2). The one in 
this collection, which had attained a considerable size, 
protruded between the lid and the globe, 

No. 1. — The lateral half of a shrunken eyeball, together 
with a piece of the upper eyelid and a large portion of the 
conjunctival sac. They were removed from a woman, aged 46, 
who, 12 years previously, had been a patient at the hospital 
with an eye affection following " low fever." The operation of 
peritomy was then performed on the eye. A year "before excision 
she stated that she was struck on the lower eyelid by a hop- 
pole, and that three days later she noticed a pimple just above 
the lashes of the upper lid, which had grown steadily larger 
and had become very painful. The eyeball measures 16 mm. 
anterio-posteriorly, and 17 mm. vertically. Hardly any corneal 
tissue is left, there is no anterior chamber, the lens is absent, 
the vitreous shrunken, and the retina detached from the ora- 



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O DESCRIPTIVE CATALOGUE OF SPECIMENS 

serrata up to the optic disc. The upper lid is much thickened 
by new growth, its palpebral margin can no longer be clearly 
defined. The growth has a papillated surface of a velvety 
appearance. Microscopically it is seen to be composed of 
numerous delicate finger-like processes, consisting of epithelial 
cells arranged around central blood-vessels and fibrous tissue, 
as is typical of papillomatous growths. 

No. 2. — The lateral half of an eyeball, a portion of the 
lower eyelid, and the lower conjunctival sac, with a melanotic 
tumour growing in the latter. They were removed from a 
patient en masse after death. No further history of the case is 
known. The eyeball appears heal thy > the cornea is somewhat 
puckered, and the retina is slightly detached, but these are 
probably post mortem changes. The lower margin of the lid 
can be seen with eyelashes along it. Between the margin of 
the lid and the globe is a large, deeply pigmented mass ; it 
measures 19 mm. by 36 mm., and embraces, without invading, 
the lower part of the sclerotic, from the equator as far forwards 
as the corneal margin, Microscopically the growth is seen to 
be a densely pigmented round-celled sarcoma. 

No. 3. — A horny growth removed from the upper eyelid of 
a man, aged 72. He stated that it began as a small wart 14 
months previously. It sprang from the free margin of the lid 
jost above the eyelashes near the outer canthus. It measures 
15 mm. in length, 11 mm. in breadth at the base, and 7 mm. in 
breadth at the tip. It is very hard, of a brownish colour, flat 
on one surface, concave on the other ; there are some hairs on 
the convex surface. 

No. 4. — A horny growth removed from the lower lid of a 
man, aged 40 ; it had been growing for two months, and was 
situated just below the lashes. It measures 9*5 mm. in length 
and 6 mm. in breadth. It is hard in consistency, of a greyish 
colour, and has some long hairs attached to its base. 

No. 5. — A horny growth, preserved in the dry state. It was 
removed from the right upper eyelid of a man, aged 36. The 
patient stated he had had a wart in that situation since he was 
a boy; a month previous to its removal it was the size of a 



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IN THE HOSPITAL MUSEUM. 9 

small hazel nut, since then it had grown rapidly, and was very 
irritable. The growth is of bony hardness, and measures from 
base to apex 23 mm. ; the greatest diameter at the base is 
26 mm. and the smallest 21 mm. Its base is convex, and the 
surface is smoother there than elsewhere. Its apex is rough, 
and presents a number of irregular points. 

"No. 6. — A horny growth, removed from the lower eyelid of 
a woman, age 71. She stated that it had been growing for two 
months. It measures 47 mm. in length, and the diameter at its 
thickest part is 6 mm. It is curved at the two ends, and has 
some hairs attached to it at one extremity. 

No. 7. — A dermoid cyst, removed from the eyelid. The 
history of the case is not known. The specimen has been 
partially divided into two. It measures 3 cm. in length, 2 cm. 
in breadth. The wall of the cyst is very thin ; the incision 
which had been made into it exposes the sebaceous contents. 

Sub series (C.) — Starting in the Cornea. 

The tumours met with in connection with the cornea 
are either cystic or solid. Cystic tumours are of extreme 
rarity. The specimen in the collection (No. 1) is the 
largest of which there is any record; it followed on a 
perforating wound, and is lined by laminated epithelium. 
Some of the surface epithelium was doubtless, at the time 
of the wound, carried into the substance of the cornea, 
and this by the proliferation and the liquefaction of some 
of its cells has produced the cyst. 

Dermoids are the commonest of the solid tumours of 
the cornea; they are congenital growths, and are nearly 
always situated at the sclero-corneal margin; so that 
some writers describe them as tumours of the conjunctiva, 
though they generally extend for some distance over the 
surface of the cornea. They are usually about the size, 
and have much, the appearance, of a split pea. Their 
minute structure resembles exactly that of skin with its 
glands and hair follicles. No specimen of them is con- 
tained in the Museum, nor is there one of a fibroma. 



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10 DESCRIPTIVE CATALOGUE OF SPECIMENS 

which form of growth has also occasionally been met 
with starting from the cornea. 

The malignant tumours of the cornea, epitheliomata 
(No. 2) and sarcomata (Nos. 3, 4, and 5), are rare: 
both start, as a rule, from the sclero-corneal margin. 
The former, in an early stage, are often mistaken for a 
simple ulcer, or a pterygium. The points which help to 
distinguish an epithelioma from these affections are the 
ragged irregular margin of the ulcerated surface, the 
peculiar dull white appearance that the ulcer presents, due 
to thickened epithelium on its surface (No. 2), and the fact 
that the ulcerated surface is raised, there being evidently 
new growth. Malignant tumours of the cornea do not at 
first extend deeply, the dense fibrous tissue of the cornea 
offering considerable resistance to their down growth. 
They tend rather to increase in area, and form large out- 
growing masses (Nos. 3, 4, and 5). 

Sarcomata growing from the sclero-corneal margin are 
sometimes partially pigmented (Nos. 4 and 5). 

No. 1. — The lateral half of the right eye of a lad aged 15. 
Two years and nine months previous to excision, he received a 
perforating wound in the centre of the lower half of the cornea 
from a stick. The iris became adherent to it, severe iritis 
ensued, and the tension became increased. Two iridectomies 
were performed with the hope of relieving this, but were 
unsuccessful. Considerable bulging at the seat of the injury 
took place, which was thought to be a.n ordinary staphylo- 
matous condition of the cornea. Situated in the lower part 
of the cornea and in the adjoining sclerotic is a large cyst, 
measuring 5 mm. antero-posteriorly and 9"5 mm. laterally. 
Microscopically, it is found to be lined with laminated 
epithelium, exactly resembling that on the anterior surface 
of the cornea. The iris is adherent to the posterior surface of 
the cornea ; part of it has been removed. The lens, which was 
much flattened from before backwards, has become somewhat 
broken in the mounting of the specimen. The retina is in situ. 
The optic disc is deeply cupped. 

(Recorded in the Trans. Ophth. Soc, vol. xii, p. 64.) 



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IN THE HOSPITAL MUSEUM. 11 

No. 2. — A portion of the front half of the eye of a man 
aged 50, who had been treated for some months for what was 
thought to be a pterygium. Several operations had been per- 
formed for its removal, after each of which it returned. A 
portion of the growth situated at the sclero-corneal margin 
was removed shortly before the excision of the eye, and micro- 
scopical sections showed it to be an epithelioma. The specimen 
shows at the outer margin of the cornea, involving part of its 
structure, and also the conjunctiva in its vicinity, a slightly 
raised new growth with an irregular margin, and of a dense 
opaque white colour. 

No. 3. — The two lateral halves of a right eyeball, partially 
separated by an antero-posterior section. It was removed from 
a man aged 38, who, about five months previously, had noticed 
a small swelling at the upper and outer part of the cornea or 
sclero-corneal margin. It increased rapidly in size, and latterly 
had begun to bleed. The eye was excised on July 12, 1858. 
About six months later, a second operation was done, but no 
details of it were kept. Two years after the second operation 
(January 4, 1861), it is noted that the growth had again 
returned, and formed, at that date, a fungating, bleeding, and 
suppurating tumour, as large as a hen's egg. The man was 
then very nervous and excitable, but had not lost flesh or 
appetite. No further history is known. The section has been 
carried through the centre of the tumour, which is about the 
size of a small cherry ; it grows from, the sclero-corneal margin, 
and is of a reddish pink colour. All the other parts of the eye 
appear healthy. Microscopical examination of the growth 
shows it to be a spindle-celled sarcoma. 

No. 4. — The upper half of a left eye. The history of it 
is not known. Springing from the outer half of the cornea 
and the adjoining sclerotic by a base 10 mm. in width, is a 
new growth, measuring 11 mm. in height. Nowhere does it 
encroach upon the cavity of the globe. It is seen at the seat 
of section to be partially pigmented. Microscopical examina- 
tion shows it to be a spindle-celled sarcoma. The lens has 
been removed from the specimen. 

No. 5. — A thick section from the front half of the right eye 



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12 DESCRIPTIVE CATALOGUE OF SPECIMENS 

of a woman aged 39. A year previous to its removal, a small 
dark growth was first noticed at the outer sclero-corneal 
margin. It gradually increased in size, and became pendulous, 
and at last painful. Starting in the subconjunctival tissue at 
the sclero-corneal margin on the outer side, is a mass of new 
growth which projects forwards 14 mm. from the surface of the 
globe. It is of a greyish colour, on section, with dark brown 
markings in it. The conjunctiva appears to extend over the 
front of the growth ; only the most superficial layers of the 
cornea and sclerotic are invaded. The other parts of the eye 
appear healthy. Microscopically, the tumour is seen to be a 
mixed, round and spindle-celled, sarcoma. 

Sub series (D.) — Starting in the Iris or Ciliary Body. 

The iris is the locality in which cystic tumours of the 
eye are most frequently met with ; solid tumours of it are 
exceedingly rare ; sarcomata are less commonly met with 
in it than in any other part of the uveal tract. 

Cystic tumours of the iris may be divided into three 
classes: — 1. Epithelial cysts; 2. Endothelial cysts; 3. 
Cysts due to the separation of the two layers of pigment 
on the posterior surface of the iris. 

The characteristics of the first class (Nos. 1 and 2), the 
epithelial cysts, are that their lining membrane is com- 
posed of several layers of laminated cells, and that they 
always follow on perforating wounds of the eye, being 
due to the implantation of some of the surface epithelium 
into the stroma of the iris. An eyelash is sometimes 
implanted into the eye, with the epithelium composing 
its root sheath adherent to it (No. 1); the tumour then 
forms around the root of the eyelash. The contents of 
these epithelial cysts is sometimes fluid (No. 2) and some- 
times semi-solid (No. 1), depending probably upon the 
source of the implanted epithelium, for it seems probable 
that the contents of a cyst formed by the implantation of 
the epithelium of the skin would be different to one 
formed by implantation of the surface epithelium of the 



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IN THE HOSPITAL MUSEUM. 13 

cornea. The semi-solid contents are found microscopically 
to consist of degenerate epithelial cells, fatty globules, 
and cholesterine crystals. These latter give, when the 
cysts are freshly opened, a pearly lustre, and they have 
consequently been termed by some, epithelial pearl 
tumours. These cysts, if left in the eye, continue slowly 
to grow, and by their expansion displace and cause 
absorption of surrounding structures (No. 2). 

No specimen of an endothelial cyst is contained in this 
collection. They can generally be effectually removed by 
operation, and do not entail excision of the eyeball. They 
differ from the epithelial cysts in that their lining mem- 
brane is composed of but a single layer of flattened cells, 
which are not implanted from without, but are produced 
from those on the anterior surface of the iris or posterior 
surface of Descemet's membrane, and therefore endothelial 
not epithelial, mesoblastic not epiblastic in origin. They 
may follow on an injury not necessarily a perforating 
wound, but also arise spontaneously. They are probably 
formed by the occlusion of the mouth of one of the crypts 
on the anterior surface of the iris. 

Small cysts formed by the separation of the two 
pigment epithelial layers of the iris, which represent the 
two layers of the anterior extremity of the secondary 
optic vesicle, are not unfrequently met with in patho- 
logical specimens in which there has been a plastic 
uveitis. The inflammatory effusion unites the posterior 
pigment layer, the pars iridis retina, to the lens capsule. 
The potential space which exists between the two layers 
then gets opened out by the accumulation of serous fluid 
in it, and the stroma of the iris and anterior layer of 
pigment epithelium are pushed forwards. Such a con- 
dition of things is indistinguishable clinically from what 
is known as iris bomhS. Separation of the two pigment 
epithelial layers by serous fluid may, however, in rare 
cases occur apart from any inflammation. A pigmented 
tumour is then found protruding through the pupil from 



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14 DESCRIPTIVE CATALOGUE OF SPECIMENS 

between the iris and lens ; that it contains fluid may be 
recognised by the vibration of its walls on movements of 
the eye. 

Sarcomata of the iris may be melanotic (No. 4) or 
devoid of pigment (No. 3), spindle or round cell, or -com- 
posed partly of both varieties. The melanotic sarcomata 
commence sometimes in a simple melanoma or congenital 
pigmented nodule of the iris (No. 4), just as melanotic 
sarcomata of the skin begin in moles of that structure. 
Leucosarcoma of the iris cannot be readily diagnosed 
from inflammatory granulomata, either tubercular or 
syphilitic, and often the effect of treatment and the pro- 
gress of the case have to be watched in order to arrive at 
a conclusion as to the real nature of the growth (No. 3). 
Sarcoma of the iris spreads rapidly back to the ciliary 
body, and early involves the angle of the anterior 
chamber giving rise to increased tension (No. 4). The 
pressure of the growth backwards causes a localised 
opacity to form in the lens (No. 4). 

The tumours of the ciliary body of which descriptions 
have been recorded are cysts, myomata, adenomata, 
glandular carcinomata, and sarcomata. No specimen of 
the three first mentioned are contained in this collection. 
There is one of a glandular carcinoma, a partly pigmented 
and partly non-pigmented growth (No. 13). That primary 
tumours of a glandular character should occur in the 
ciliary body is of considerable interest, affording con- 
firmatory evidence as to the glandular character of the 
tubules, found in bleached sections of the ciliary body 
dipping clown from its pigment epithelial lining, from 
which, doubtless, these growths take origin. 

Sarcomata of the ciliary body, like those of other parts 
of the uveal tract, differ in their structure, being round- 
celled, spindle-celled, or alveolor, and in the amount of 
pigmentation. Leucosarcoma of the ciliary body (No. 6) 
is less frequent than melanotic sarcoma. The melanotic 
sarcoma may be densely black (Nos. 7, 8, 9, and 10) 



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IN THE HOSPITAL MUSEUM. 15 

or of a grey colour with brown markings (Nos. 11 
and 12). 

The tumours of the ciliary body wdiieh are white or only 
partially pigmented, appear clinically deeply melanotic, 
because the pigment epithelium that overlies them is 
what is seen through the lens (Nos. 6 and 11). It is not 
until a section of the growth has been made that its real 
colour can be determined. Sarcomata starting in the 
ciliary body tend to spread forwards to the iris, and back- 
wards into the choroid. They invade the root of the iris, 
and appear at the periphery of the anterior chamber, and 
if pigmented produce a condition very much resembling an 
iridodialysis (No. 7, Fig. 11). They may find exit from the 
eye along the track of one or more of the anterior ciliary 
blood vessels through the sclerotic, and appear as sub- 
conjunctival pigmented nodules a short distance from the 
corneal margin (No, 7, Fig. 11). Occasionally, though not 
usually, sarcomata of the ciliary body grow in a peduncu- 
lated manner, as is frequently the case in sarcomata of 
the choroid. They are then found to have a broad base 
of attachment, a constriction, and to terminate internally 
in a rounded knob (Nos. 5, 9, and 12). The constriction 
is found microscopically to be the position at which the 
growth has burst through the lamina vitrea ; when no 
longer confined beneath it the tumour grows more 
luxuriantly, and expands into a rounded mass. 

In specimens of tumour of the ciliary body, the side 
and posterior surface of the lens are frequently found 
much pressed upon, its position, shape, and transparency, 
being consequently affected (Nos. 6, 7, 10, and 11). 
Occasionally the lens capsule becomes perforated by the 
growth, and its cells are found infiltrating the lens 
substance (No. 5). 

Large tumours of the ciliary body may exist without 
there being any general shrinking of the vitreous or 
detachment of the retina (Nos. 6, 7, and 10). Generally, 
if a tumour has existed for some time the nutrition of the 



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16 DESCRIPTIVE CATALOGUE OF SPECIMENS 

vitreous humour becomes affected, it contracts, and 
secondary detachment of the retina ensues (Nos. 5, 8, 9, 
11, and 12). It is not until the vitreous has become 
completely shrunken and the retina everywhere detached 
from the choroid that glaucoma sets in (Nos. 5 and 13). 

No. 1. — A portion of the front half of the right eye of a lad, 
aged 8. A year and seven months previous to its removal it 
had been wounded by a piece of wire ; seven months after the 
injury, when he first came under observation, an eyelash was 
seen in the anterior chamber, surrounding the root of which 
was a small nodule, wedged in between the iris and cornea. 
The lens was cataractous, and there were posterior synechia. 
The eyelash was removed through an incision in the cornea, but 
only a portion of the growth was got away. A year later the 
eye became very inflamed and irritable ; the tumour had grown 
considerably, measuring 7 mm. in its longest diameter. On 
one side of the specimen, situated in the iris tissue, is seen a 
silvery-greyish oval mass of loose consistency. The iris tissue 
in front of it is pushed forwards into contact with the back of 
the cornea, and the iris tissue behind it is slightly displaced 
backwards behind the plane of the posterior surface of the iris 
on the opposite side. The anterior chamber on the side 
opposite to the growth is of good depth. The lens is in great 
part absent, a thin layer of its substance only remaining. The 
vitreous is of good consistency. Microscopical examination of 
the growth shows it to be a cyst lined by laminated epithelium, 
and containing degenerate epithelial cells, fat globules, and in 
the recent state cholesterine crystals. 

(Recorded in the Trans. Ophth. Soc, vol. xiii, p. 199.) 

]Sr 0# 2. Half of a shrunken eyeball removed from a man 

aged 40. It had been wounded 28 years previously by a 
"tip-cat," and had recently become painful. The specimen 
has been cut into two pieces. The eyeball is almost square in 
shape. The sclerotic is somewhat thickened and puckered. 
The cornea is shrunken, its vertical diameter being diminished. 
Ln the interior of the eyeball is a large cavity, which measures 
11-5 mm. antero-posteriorly, and 12 mm. laterally. It is bounded 
anteriorly by the posterior surface of the cornea. Posteriorly 



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IN THE HOSPITAL MUSEUM. 17 

and laterally its walls present many elevations and depressions. 
Between the posterior wall of the cyst and the sclerotic is a 
mass of pigmented tissue, in which is some Lone. There is no 
lens in the eye ; the position of its tnnics cannot be dif- 
ferentiated macroscopically. Microscopical examination shows 
that the whole of the cavity in the interior of the globe is 
lined by laminated epithelium, closely resembling that normally 
found on the anterior surface of the cornea. At the sclero- 
corneal margin is seen the line of a cicatrix, embedded in which 
is a second small cyst lined by laminated epithelium. 
(Recorded in the Trans. Ophth. Soc, vol. xi, p. 133.) 

Wo. 3. — The front half of an eye, from which the cornea 
has been removed. It was excised from a lad, aged 17; no 
further history is known concerning it. A yellowish nodulated 
tumour about the size of a split pea occupies the whole width 
of that portion of the iris on which it is seated, and projects 
into the pupil so as to cover about one quarter of its area. Tbe 
rest of the iris looks perfectly healthy, the pupil being round and 
free from any adhesion to the lens-capsule. The other parts of 
the eye shown in the specimen are healthy. No microscopical 
examination has been made of the growth, and it is doubtful 
whether it is an inflammatory granuloma or sarcoma. The 
absence of other inflammatory changes in the iris is in favour 
of its being a sarcoma. 

No. 4. — A portion of the anterior half of the right eye of 
a woman, aged 39, She stated that three years before excision 
she noticed a discolouration of its inner part. The swelling 
and discolouration, she said, slowly increased. A few months 
before excision she could only see light from dark with the 
eye, the last fortnight pain had set in. Anew growth, of a 
deep black colour on section, involves the iris on the inner 
side in its whole length, from the pupillary margin to its root, 
and also the ciliary processes. It is thickest about on a level 
with the sclero-corneal margin, where it measures 4 mm. across. 
The anterior surface of the growth is for some distance in con- 
tact with the back of the cornea, which is somewhat thinned 
and bulged in front of it. The anterior surface of the lens on 
the inner side is somewhat indented by the pressure of the 
VOL. XIV. 



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IS DESCRIPTIVE CATALOGUE OP SPECIMENS 

growth, and there is a white opacity of it there. The colour 
of that portion of the iris not involved in the growth was 
described clinically as for the most part of a tawny yellow, 
curiously mottled with patches and streaks of deep brown or 
black pigment. The iris of the patient's left eye was of a pale 
bluish-green colour. Microscopical examination shows the 
growth to be a melanotic spindle- celled sarcoma. 

No. 5. — The outer half of the left eye of a man, aged 33. 
He bad had an injury, which bruised it, five years previous 
to excision. The sight had only been failing 10 months ; it 
commenced to go on the outer side. Starting from the upper 
part of the ciliary body and anterior portion of the choroid is a 
large mass of deeply pigmented new growth, which extends 
inwards to the middle line of the globe and backwards, by a 
rounded extremity, behind the equator. There is a constriction 
in the growth about its centre. The retina is completely 
detached from the choroid, both on the side of the growth and 
on that opposite. The inner surface of the retina from the two 
sides is apparently in contact. No remnant of the vitreous 
is visible, the retina seeming to embrace the back of the lens. 
The lens and iris are both pressed forwards, the latter being in 
contact with the back of the cornea. The portion of the lens in 
contact with the growth is seen to be infiltrated by it. Micro- 
scopically the tumour is found to be a small spindle- celled 
sarcoma. 

No. 6. — The lateral half of the left eye of a man, aged 29. 
Three years previous to coming to the hospital he first acciden- 
tally discovered it was blind. Never at any time had he had 
any pain in the eye. Springing from the lower and outer part 
of the ciliary body by a base which extends from the root of 
the iris to a little behind the ora serrata is a yellowish- 
coloured tumour of somewhat cavernous structure and about 
the size of a marble. It extends inwards as far as the centre 
of the globe, and presses upon and indents the posterior surface 
of the lens. The uveal pigment covers the whole inner surface 
of the growth. The retina, when the eyeball was first opened, 
was in situ. It has become somewhat rucked in mounting the 
specimen. Microscopically the growth is found to be a small 



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>val-celled sarcoma, devoid of pigment, but very vascular and 
laving large empty spaces in it, lined by endothelial cells. 

No. 7. — The inner half of the right eye of a man, aged 56. 
["he sight had commenced to fail in it three months previous to 
ts removal. He had had an injury to it 30 years before from a 
^as-pipe. There is a large deeply pigmented growth springing 
rom the lower part of the ciliary body, and extending from 
he root of the iris to the equator of the globe. It has ex- 
ended forwards and invaded the root of the iris, so that it 
howed through the cornea at the periphery of the anterior 
hamber. It presses on and has considerably flattened the side 
f the lens, but does not reach inwards as far as the centre of 




io. 11. — Specimen No. 7, showing a melanotic sarcoma of the ciliary body 
and a small extraocular nodule a short distance from sclero-corneal margin. 

ie globe. There is a small nodule of pigmented growth 
sternal to the sclerotic overlying the intraocular mass, a 
lort distance from the sclero-corneal margin (Fig. 11). The 
^tina is in situ. The vitreous is not at all shrunken, and is of 
lod consistency. Microscopically the growth is found to be 
melanotic spindle-celled sarcoma. 

A year and eight months after the removal of jkli0d $jSckfitt?Ie 
itient was alive and well. 



20 DESCRIPTIVE CATALOGUE OF SPECIMENS 

No. 8. — Half of a left eyeball, opened by an antero-posterior 
oblique section ; the history of it is not known. Growing 
from the upper and inner part of the ciliary body is a deeply 
pigmented growth. Its base extends from the root of the iris 
backwards to a short distance behind the equator of the globe. 
Internally, its apex extends slightly beyond the middle of the 
globe. The angle of the anterior chamber is widely open. 
The lens is not altered in shape. The vitreous is much 
shrunken, and the retina is extensively detached from the 
choroid, and folded. Microscopically the growth is found to be 
a melanotic spindle-celled sarcoma. 

No. 9. — The inner half of the left eye of a woman, aged 46. 
The sight of it had commenced to fail two months previous to 
its removal. She had never at any time received any injury to 
it. There is a deeply pigmented growth springing from the 
upper part of the ciliary body, by a base which extends from 
the root of the iris to a little behind the equator. The growth 
has a constriction in it about its centre. It terminates inter- 
nally in a rounded knob which extends beyond the centre of 
the globe. The angle of the anterior chamber is narrowed, but 
not closed. The lens is not altered in shape, but the growth 
is in contact with its posterior pole. The vitreous is much 
shrunken, and the retina is everywhere detached from the 
choroid. Microscopically the growth is found to be a melanotic 
spindle-celled sarcoma. 

No. 10. — The front portion of the lateral half of the right eye 
of a woman,^aged 63. It had dark patches of pigmentation in 
the sclerotic and a hazel-coloured iris. The dark patches, she 
stated, had always been present. Failure of vision in the eye 
had only been noticed a short time before its removal. A very 
deeply pigmented tumour is seen to grow from the inner 
portion of ciliary body and choroid. The main mass of the 
growth is from the ciliary body, but the choroid nearly as far 
back as the margin of the optic nerve, was thickened. The 
growth is seen to embrace the inner side of the lens, the cortical 
layers of which appear very degenerate. The whole uveal 
tract is unusually deeply pigmented. In the reflection of the 
specimen seen in the mirror beneath it, an extensive patch of 



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IN THE HOSPITAL MUSEUM. 21 

pigmentation in the sclerotic is shown. The retina is in situ. 
Microscopically the growth is found to be a melanotic, round 
and small spindle-celled sarcoma. 

No. 11. — The lateral half of a right eye removed from a 
woman, the history of it is not known. A large oval- shaped 
tumour is seen growing from the lower and inner part of 
the ciliary body ; its base extends from the root of the iris 
backwards to behind the equator of the globe, and its apex 
inwards to beyond the middle line ; it is of a greyish colour on 
section with some dark brown markings in it. The whole of 
its inner surface is covered by the pigment epithelium. The 
anterior chamber is very shallow, and the lens much pressed 
upon and misshapen. The retina is folded, and detached from 
the choroid, but adherent to the optic disc and to the apex of 
the growth. The vitreous is considerably shrunken. Micro- 
scopical examination of sections of the specimen show the 
tumour to be an alveolar round-celled sarcoma. 

No. 12. — The lateral half of an eye, the history of which is 
not known. Growing from the lower and inner part of the 
ciliary body is a pedunculated tumour, of a greyish colour on 
section, with dark brown markings in it. Its base extends 
from the root of the iris, which it invades, to about the equator ; 
it has a constriction in it, and terminates internally in a 
rounded knob, the apex of which does not reach the middle 
line of the globe. The anterior cLamber is of normal depth 
the lens is not pressed upon or misshapen. The retina is de- 
tached from the choroid, but adherent to the optic disc and the 
apex of the growth. The vitreous is shrunken. There is a 
coagulated albuminous material between the retina and choroid. 

No. 13. — The inner half of the left eye of a woman, aged 28, 
which had become inflamed, and of which the sight had com- 
menced to fail six months previous to its removal. The 
tension at the time of excision was -f-1. Growing from the 
upper part of the ciliary body is a tumour, which extends from 
the root of the iris back to a little distance behind the 
equator. It presses on the upper part of the lens, and behind, 
it reaches the middle line of the globe. The anterior three- 
fifths of the growth is densely black, and the posterior two- 



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22 DESCRIPTIVE CATALOGUE OF SPECIMENS 

fifths white. The line separating these two different coloured 
parts is sharply defined. The anterior chamber is shallow ; its 
angle is narrowed by the contact of the root of the iris with the 
periphery of the cornea. The vitreous is exceedingly shrunken 
The retina is everywhere detached from the choroid, but remains 
adherent to the optic disc. Microscopical examination shows 
the growth to be largely composed of cells of an epithelial type, 
and arranged in loculi, suggestive of a glandular structure. 

No. 14. — The lower half of the left eye, divided into two 
portions and mounted in separate cells. It was removed from 
a woman, aged 26, no further history is known concerning it. 
A new growth, of a white colour on section, springs from the 
ciliary body and anterior portion of the choroid, by a base 
which extends from the root of the iris to a little behind the 
equator of the globe. It extends inwards and backwards, and 
ends in a round surface which does not quite reach the middle 
line of the globe. In the recent state the retina was in appo- 
sition with the choroid everywhere, except where the tumour 
had raised it up. Microscopically the growth is found to 
consist of round and spindle-shaped cells. 

Syb series (E). — Starting in the Choroid. 

The forms of new growth which have been met with 
in the choroid are cysts, nasvi, carcinomata, and sarcomata, 
Cysts are very uncommon, and when they occur are 
situated in the loose lymphatic tissue between the choroid 
and sclerotic, constituting the lamina suprachoroidea. 
Some of them seem to be partial detachments of the 
choroid from the sclerotic, resulting in the first place 
probably from haemorrhage (No. 1), In others there is 
considerable thickening of the loose lymphatic tissue, with 
large spaces in it, constituting cysts, (Series I, sub- 
series E, No. 1.) 

Nsevi of the choroid are also very rare, but occur some- 
times in association with nsevi of the face. There is no 
specimen of a simple naavus of the choroid in this collec- 
tion, but there is one of an exceedingly vascular tumour 
which, microscopically, is seen to be composed of oyal and 



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IN THE HOSPITAL MUSEUM. 23 

round cells and naevoid tissue, and which is best described 
as a na3void sarcoma (No. 39). Carcinoma when it occurs 
in the choroid is always secondary to carcinoma elsewhere, 
generally of the breast ; there is no specimen of this form 
of growth in the museum. Sarcomata are by far the 
commonest form of growth met with in the choroid, they 
may be composed of oval, round, or spindle-shaped cells. 
They vary, considerably in the extent and density of their 
pigmentation. They are most often densely black 
(Nos. 2, 11, 18, 21, 24, 26, 29, 34, 35, 38, 40, and 41), but 
may be quite white (Nos. 4, 5, 6, 16, 20, and 25), grey 
(Nos. 3, 31, 36, and 37), fawn coloured (Nos. 9, 10, 23, and 
27), or piebald (Nos. 7, 8, 12, 13, and 37). 

In consistency, also, they present many differences ; 
they are usually firm, but may be flocculent (Nos. 4 and 
20), spongy (No. 23), and in rare cases show a tendency 
to cystoid degeneration (No. 5). Some on section have a 
peculiar foliated appearance very similar to the convolu- 
tions of the brain (Nos. 9 and 38) Fig. 13. 

Sarcomata of the choroid may be diffuse or circum- 
scribed. When diffuse they extend over a large area of 
the choroid without giving rise to any one large mass 
(Nos. 18 and 35). The area occupied by the base of a 
localised tumour varies considerably irrespective of its 
size. Occasionally, besides the main mass of growth, 
secondary little isolated patches are seen scattered about 
the choroid (No. 40). 

A sarcoma starting in the choroid is situated at first 
beneath the elastic lamina, which structure is raised in 
front of it (No. 31). and as the tumour grows, gradually 
becomes more and more stretched, until at last it gives 
way and the tumour extends through the gap (Nos. 6 
and 28). The tumour then, being no longer confined 
in its growth by the pressure of this membrane, com- 
mences to fungate out into a rounded knob (Nos. 3, 4, 7, 
25, 26, 32, 33, and 41), Fig. 12, a constriction being left at 
the point where it burst through the elastic lamina. 



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24 DESCRIPTIVE CATALOGUE OF SPECIMENS 

The retina as well as the elastic lamina becomes raised 
up in front of the tumour (Nos. 11, 31, and 36) ; usually, 
very soon after the appearance of the growth, the retina 
becomes detached from the choroid, serous fluid collecting 
between the two tunics. The retina is sometimes de- 
tached from the tumour as well as from the choroid 
(Nos. 7, 28, 32, 33, 35, and 41) ; more commonly it remains 
adherent to the apex of the growth (Nos. 3, 12, ,13, 14, 24, 
25, 30, and 38), Fig. 12. 

It is not until late in the disease that the retina 
becomes invaded by sarcomatous tissue (No. 15). The 
detachment of the retina may be due to the shrinking of 
the vitreous from some interference with its nutrient 
supply, caused by the growth, or to the pressure of serous 
fluid exuded from the choroidal vessels, resulting from 
obstruction caused by the growth to the exit of venous 
blood. As a case progresses the shrinking of the vitreous 
and detachment of the retina increases, until ultimately 
hardly anything is left of the former, and the retina, 
much folded and plicated, appears to lie in direct con- 
tact with the back of the lens (Nos. 32, 33, and 4L). The 
accumulation of subretinal contents continuing, causes the 
lens and iris to be pressed forward, the anterior chamber 
to become shallow, and its angle to be closed (Nos. 3, 12, 
13, 15, 24, 28, 32, 33, 37, 40, and 41). The further 
escape of intraocular fluids being thus obstructed, in- 
crease of tension results, the lamina cribosa is displaced 
backwards, and the optic disc becomes atrophied and 
cupped (No. 10). 

Occasionally the growth extends forwards into the 
anterior chamber (Nos. 16 and 19), invades the cornea, 
protrudes through a perforation in it, and forms a large 
fun gating mass anteriorly (Nos. 27 and 34j). More often 
it gains exit from the eye through the sclerotic, at first 
along the course of one of the blood vessels. The extraocular 
nodules or masses are situated equatorially at the place 
of exit of the venae vorticose (Nos. 14, 15, and 40), or, 



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IN THE HOSPITAL MUSEUM. 25 

posteriorly, where the posterior ciliary arteries enter the 
eye (Nos/ 18, 20, 22, 26, 34, and 35). The growth pro- 
bably extends along the lymphatic sheaths of the blood 
vessels; it does not extend out of the eye and form extra- 
ocular masses only when the interior of the globe is full 
and there is no more room for its expansion there, for 
extraocular masses are frequently met with when the 
intraocular growth is not very large (Nos. 12, 17, 18, 22, 
26, and 35). Sometimes in such cases the extraocular 
growth will press upon and flatten the side of the globe 
which the intraocular growth has not yet involved 
(No. 29). Another position in which sarcoma may extend 
out of the eye is along the optic nerve ; it penetrates into 
the space between the pial and dural sheaths and 
expands there (Nos. 8, 23, 29, 33, and 35). The extra- 
ocular growths are usually pigmented or unpigmented 
like the intraocular growths with which they are 
associated (Nos. 14, 15, 18, 20, and 40). Occasionally, 
however, when the intraocular growth is deeply pig- 
mented the extraocular growth is white (No. 12). When 
a sarcoma of the choroid has existed for some time, the 
sclerotic often becomes much invaded by it (Nos. 11, 12, 
15, 17, 19, 21, 23, 29, 34, and 40). Shrunken blind eyes 
seem specially predisposed to this form of growth (Nos. 
2, 16, 20, 21, 22, and 23). 

No. 1. — The lateral half of the right eye of a woman, aged 
40. Two months previous to its removal an iridectomy was 
performed on it for absolute glaucoma. The following day the 
lens was found to have escaped, and the vitreous was pro- 
trading. There is some puckering and thickening seen in the 
neighbourhood of the iridectomy incision, A small portion of 
the cortex of the lens is seen lying behind the iris ; the vitreous 
is exceedingly shrunken. The retina is completely detached, 
and forms a thin band passing through the centre of the globe. 
Between the choroid and sclerotic is some grey fibrous- 
looking tissue, in which four large oval spaces are seen. 



I 



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No. 2. — Half of a shrunken eye with a large melanotic 
growth attached. It was removed from a man aged 70, whc 
15 years previously had suffered from dimness of sight in it 
for which he had undergone an operation. He stated thai 
12 months before excision he first noticed a little pimple ir 
his right lower lid, which had gradually enlarged. The cornea 
is seen to be very small and thickened. The sclerotic is 
thickened and much puckered, the melanotic growth starting 
in the interior of the globe, protrudes through a gap in it 
External to the globe the growth forms a large densely pig- 
mented mass which encircles half its circumference. The 
growth appears to be everywhere encapsuled except posteriorly, 
where it has been cut into during removal and presents a 
ragged surface. The iris cannot be distinguished. The lens 
lias calcareous deposits in it, and the vitreous is now replaced 
iy fibrous tiVsue. Microscopically the growth is seen to be a 
mixed, round and spindle-celled, melanotic sarcoma. 

No. 3. — A portion of the inner half of the left eye of a man, 
aged 59, the sight of which commenced to fail on the outer side 
two years previous to its excision. During the last eight 




Fig. 12.— Specimen No. 3 showing a sarcoma growing from A lie choroid, 
with a const riction in it, and expanding intcrii9#^*iW.Qfij^liSed knob. 



IN THE HOSPITAL MUSEUM. 



21 



months the eye was quite blind, and for four months it had 
been painful. A grey coloured growth is seen springing from 
the posterior part of the choroid by a broad base. It has a 
constriction in its centre, expanding internally into a rounded 
knob. The retina is detached from the choroid, but is 
adherent to the apex of the growth. The angle of the anterior 
chamber is closed by contact of the root of the iris with the 
periphery of the cornea. Microscopically the growth is seen 
to be a spindle-celled sarcoma. The patient was alive and well 
2 J years after the removal of the eye. 

(Recorded in the R.L.O.H. Reports, vol. xiii, p. 157.) 

N 0< 4. — p ar t of the posterior half of the right eye of a man, 
aged 64. No further particulars are known concerning the 
history of the patient. Growing from the choroid in the region 
of the yellow spot is a tumour about the size of a cherry ; it is 
quite unpigmented, soft, and flocculent looking. The upper 
part is uniformly rounded (a portion of it has been cut away) ; 
it spreads out somewhat widely at its base where it starts 
from the choroid ; a constriction, completely encircling it, marks 
off the rounded portion from the base. 

No. 5. — The lateral half of an eye from a man, aged 54, 
upon which two operations had been performed, one an iridec- 
tomy. At the time of excision it presented all the symptoms of 
glaucoma, it had no perception of light, and the iridectomy 
scar was staphylomatpus. From the upper and back part of 
the choroid a tumour projects downwards to within 3 mm. of 
the equatorial part of the globe below, it thus occupies the 
greater part of the posterior half of the eye. Its base is about 
7 mm. wide, beginning at the equator and extending back- 
wards. The hindermost surface of the tumour is almost in 
apposition with the disc. The section of it shows the part 
near the base to be homogeneous, white, and moderately firm ; 
the larger part, however, that furthest from the base, is soft, 
reddish-brown, from blood staining, and has several cyst-like 
cavities which contained bloody, grumous fluid. There is a 
constriction in the growth near its base. The retina which 
was detached has been removed from the specimen ; the sub- 
retinal space in the recent specimen contained much blood. 



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28 DESCRIPTIVE CATALOGUE OF SPECIMENS 

The lens is absent. Microscopically the growth is seen to be 
a sarcoma composed of spindle and oat-shaped cells. 
(Eecorded in R.L.O.H, Reports, vol. vii, p. 618.) 

No. 6. — The front half of the right eye of a boy aged 12. 
It is stated, " the growth appeared six months before excision 
and occupied part of the iris and aqueous chamber ;" no 
other details are known. A somewhat conical shaped tumour, 
with a deep indentation on one side of it, springs from the 
anterior part of the choroid by a wide base. Its cut surface 
shows it to be an nnpigmented growth, its inner free surface 
is covered by the pigment epithelium. 

No. 7. — The lower half of a right eye of the history of which 
no further details are known. From the temporal side of the 
choroid, by a base which extends from a little behind the 
equator to the margin of the disc, anew growth is seen to start. 
It has a ring of constriction in it marking off a rounded knob 
from the basial portion. Its cut surface shows part of it to 
be darkly pigmented, but most of it of a light colour with a few 
dark streaks. The retina is detached on both sides from the 
optic disc up to the ora serrata, the sub-retinal space being 
occupied by coagulated albuminous fluid. 

No. 8. — One hinder quarter of the left eye of a man aged 40, 
of the history of which no further details are known. Spring- 
ing from the posterior half of the choroid, and occupying nearly 
the whole interior of the specimen is a new growth, which on 
section is of a mottled black and white colour. Its free surface 
is undulating and on the whole rather concave. On the side of 
the optic disc towards the centre of the growth, it has extended 
backwards between the sclerotic and the optic nerve into the 
outer sheath of the latter. 

No. 9. — The lateral half of the left eye of a woman, aged 50. 
No further history of the eye is known. The whole cavity of 
the globe posterior to the lens is filled by a brown-coloured 
new growth, which springs by a broad base from the lower part 
of the choroid about its equator. The brown colour is partly 
due to blood staining, partly to melanosis. On magnifying the 
cut surface of the tumour, it is seen to present a foliated 



k 



IN THE HOSPITAL MUSEUM. 29 

appearance closely resembling the convolutions on the surface 
of the brain. 

No. 10. The outer half of the right eye of a man, aged 40. 
Five years previous to excision he had an attack of sponta- 
neous inflammation in it lasting a few days and leaving per- 
manent dimness of sight ; he had repeated similar attacks, and 
the eye became quite blind ; the last attack set in three weeks 
before excision, the tension was increased, the pupil dilated 
and fixed and the conjunctiva greatly chemosed. A fawn- 
coloured tumour fills about two-thirds of the interior of the globe 
behind the lens. It grows from the choroid by a wide base in 
the yellow spot region. The part of the globe behind the lens 
unoccupied by tbe tumour is filled with blood-clots. The optic 
disc is cupped and the growth extends into and fills the cup. 

JSTo. 11. — The inner half of the left eye of a man, aged 58, 
which commenced to be painful and in which the sight began to 
fail two years before excision. At the time it was removed the 
eye was quite blind, its tension was increased, and a pigmented 
nodular growth could be seen beneath the upper part of the 
ocular conjunctiva. The globe is considerably enlarged and 
altered in shape by the protrusion of its upper wall, owing to 
the growth of a large melanotic tumour at its upper part. The 
tumour is attached to the choroid and ciliary body from the 
optic disc behind to the corneal margin in front. At its 
posterior part it projects into the globe beyond the level of the 
lower border of the lens and has pushed the retina in front of 
it. When the eye was first opened the remainder of the retina 
was in situ. The sclerotic in the upper hemisphere cannot be 
recognised except near the optic disc. The growth external to 
the globe overlaps slightly the sclerotic which is left at the 
sclero-corneal margin, extending forwards between it and the 
conjunctiva. In the recent state the lens was opaque and in 
apposition with the cornea. 

No. 12. — The lateral half of the left eye of a woman, 
aged 38. She stated that it became blind while she was lying-in 
with her sixth child, four years previous to excision ; there w r as 
no pain in it until two years later ; about 12 months before 



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30 DESCRIPTIVE CATALOGUE OF SPECIMENS 

excision the globe commenced to enlarge. A large partly pig- 
merited growth is shown in the upper and posterior part of the 
globe; it has caused considerable expansion and thinning of the 
sclerotic, and has perforated it at the posterior and upper part. 
There is a large extraocular mass of growth above the optic 
nerve which is unpigmented. The tumour has evidently 
started in the choroid and pushed the retina downwards in 
front of it. The retina at the lower part is detached, The 
angle of the anterior chamber is narrowed by the apposition of 
the root of the iris and the periphery of the cornea. The 
patient died about 17 months after removal of the eye with 
growths in the liver, glands of groins and axillaB, and skin of 
abdomen. 

(Recorded in R.L.O.H. Reports, vol. vi, p. 389 and vol. ix, 
p. 42.) 

ISTo. 13. — The lateral half of the left eye of a woman, 
aged 20. She was the sixth child of the patient from whom 
specimen 12 was removed. She first noticed a defect in the 
sight of the eye four months previous to its excision. A 
mottled black and white coloured growth is shown filling more 
than half the interior of the globe behind the lens. It starts 
from a large base which extends from the ciliary body to 
the margin of the optic disc. The retina is detached from the 
choroid on the side opposite to the growth. The angle of the 
anterior chamber is narrowed by apposition of the root of the 
iris and cornea. Microscopically the growth is found to be a 
spindle-celled sarcoma. 

(Recorded in R.L.O.H. Reports, vol. xiii, p. 162.) 

No. 14, — The lateral half of a left eye, the history of which 
is not known. A large highly pigmented growth springs from 
the lower part of the choroid, its base extending from just 
below the optic disc to the sclero-corneal margin. At about the 
centre is a deep groove dividing the growth imperfectly into 
two, so that it looks as if the entire tumour had been formed 
by the partial junction of two smaller ones. The retina is 
adherent to part of the upper surface of the tumour, and is 
elsewhere detached, except at the optic disc and ora serrata. 
The lens is considerably displaced upwards by the growth. A 



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IN THE HOSPITAL MUSEUM. 31 

little in front of the equator the growth is pushing through a 
large aperture in the sclerotic, and forms a pigmented extra- 
ocular tumour as large as a small bean, beneath the tendon of 
the inferior rectus muscle. This part of the tumour has the 
same colour as the intraocular mass. 

No. 15. — The outer half of the right eye of a man, aged 58. 
No details concerning its history are known. The interior 
of the globe is almost entirely filled by an irregularly pig- 
mented tumour which has grown from the upper hemisphere 
downwards, until its free surface is separated from the inner 
surface of the opposite portion of the choroid only by a d arrow 
chink. No retina is perceptible. In the upper equatorial 
region external to the sclerotic, there is a large irregular mass 
of growth similar in appearance to that filling the interior of 
the eye. The position at which the tumour perforated the 
sclerotic is not known. The extraocular portion of the growth 
is rather more highly pigmented than the intraocular. The 
orifices of many large vessels are seen in section in the latter 
part. The lens and iris are displaced forwards, there is scarcely 
any anterior chamber left. The growth is seen extending back 
into the optic nerve a little beyond the level of the lamina 
cribrosa. 

No. 16. — The two lateral halves of an eye mounted in 
separate cells. No history concerning it is known. It is much 
altered in shape and only the sclerotic, cornea, and part of the 
choroid can be made out. The interior of the eye is entirely 
filled by a mass of unpigmented growth. On one side of the 
globe the anterior part of the sclerotic can alone be traced, 
the tumour having invaded and perforated it posteriorly. It 
there forms a large extraocular mass. The choroid can be 
recognised as an irregular pigmented line surrounded by 
growth. There is no note of a microscopical examination, and 
it is rather uncertain whether the tumour is really sarcomatous. 

No. 17. — The lateral half of an eye, the history of which is not 
known. On one side of the interior of the specimen, extending 
from the equator of the globe backwards to the optic nerve 
which it encircles, is a pinkish-white coloured growth with 
some brown streaks in it, involving the choroid and sclerotic 



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32" DESCRIPTIVE CATALOGUE OF SPECIMENS 

coats. At its thickest part it measures 9 mm. in width. It 
appears to have started in the choroid and extended outwards. 
There is some detachment of retina. 

No. 18. — The lateral half of a right eye with a mass of 
melanotic growth attached to its outer surface posteriorly. It 
was removed from the right orbit of a man aged 56, who had 
, noticed failure of sight and irritability of the eye eight years 
previous to its removal. In the course of two years it went 
blind. Prominence of the eye was not noticed until the last 
six months; it had increased rapidly the last two months. The 
shape and size of the eye itself are about normal. The lens 
and retina with some subretinal effusion have been removed 
from its interior and mounted in a separate cell. In the recent 
state the lens was opaque and yellow, and the retina was 
detached from the choroid. The inner surface of the choroid 
is mottled by the presence of very large irregularly shaped 
patches of dark and light colour. The dark patches are the 
more extensive and are much darker than the normal choroid. 
The pale areas on the other hand are lighter than normal choroid, 
and are evidently patches of atrophy through which the 
sclerotic shows distinctly. At the seat of section of the dark 
patches, the choroid is seen to be considerably thicker than 
normal. Attached to the outer surface of nearly the posterior 
half of the sclerotic is a large deeply pigmented tumour, the 
hinder part of which is wanting, but which when entire must 
have been about the size of a hen's egg. The sclerotic to 
which it is attached is nowhere, so far as is shown, in the least 
thinned. It is streaked, however, in several places with dark 
lines, which are probably the sheaths of blood vessels infil- 
trated with sarcoma cells. Microscopically the growth is seen 
to be a spindle-celled melanotic sarcoma. 

No. 19. — The outer half of the right eye of a man, aged 44. 
The further history of which is not known. The globe is 
slightly shrunken, its interior is quite filled with a yellowish 
firm growth, probably choroidal, although its origin cannot 
now be definitely determined. Very little healthy choroidal 
tissue, can be seen. The sclerotic is considerably thickened 
from behind as far as the equator; between the equator and 



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IN THE HOSPITAL MUSEUM. 33 

cornea at the upper part it becomes suddenly much thinner 
than normal, and staphylomatous ; on its outer surface, at the 
junction of the thick and thin part, there is a small nodule of 
new growth. The cornea appears healthy, but the growth, 
which has extended into the anterior chamber, is almost in 
contact with its posterior surface. 

No. 20. — Two halves of a shrunken g]obe with a new 
growth starting from the choroid, and a large extraocular 
tumour attached. No history is known concerning the eye, 
and it is uncertain whether the shrunken state of the eye 
preceded the growth, or whether it resulted from the growth. 
The cornea has apparently sloughed away, the sclerotic is 
thickened and puckered. The eye is filled everywhere, except 
at the anterior part, by a mass of soft new growth, for the 
most part non-pi gmented. To the outer surface of the pos- 
terior part of the sclerotic, a similar growth adheres, forming 
a w r ell-defined tumour the size of a walnut. The optic nerve 
has been cut very long, and its sheath is much thickened. 

No. 21. — The eye of a woman, aged 50, partially divided 
into two by a vertical incision from behind, and a large extra- 
ocular mass of growth. Five years before its removal, the 
sight commenced to fail, and the eye went quite blind in the 
course of three months. There was no pain in it until eight 
months before excision ; a little later, the patient noticed a bluish 
mass forming at the upper part of the eye, and it commenced 
to shrink. The globe is very much shrunken, and the sclerotic 
much thickened and irregularly puckered ; its interior is 
entirely filled by a mass of deeply pigmented new growth. 
In the upper part of the sclerotic there is a gap, through 
which the pigmented growth is passing, and over which the 
large extraocular mass is lying. The lens is opaque, and the 
retina depressed downwards and forwards. 

No. 22. — The lateral half of a left eyeball, with an extra- 
ocular mass of growth attached to it posteriorly ; it was 
removed from a man aged 69, the sight of it having been 
impaired by a blow from the twig of a tree many years 
previous to excision. Twelve years before excision, the 
remaining sight was destroyed by an inflammatory attack, 

VOL. XIV, D 



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34 DESCRIPTIVE CATALOGUE OF SPECIMENS 

and subsequently it was subject for several years to recurrent 
attacks of inflammation. Finally, five months before excision, 
the eye was noticed to bulge forwards, and the pain became very 
severe. The cornea is smaller than normal, puckered, and irregu - 
lar. There is no trace of the lens or its capsule. The choroid 
is universally but irregularly thickened, it is everywhere inti- 
mately adherent to the sclerotic. The retina is much thickened 
in front of the equator, and hardly recognisable. The pigment 
epithelial layer is almost entirely absent. Growing from the 
optic disc is a pyramidal-shaped mass, with a firm and homo- 
geneous base, but a spongy surface, from the presence of many 
large blood vessels. The inner sheath of the optic nerve is 
considerably thickened by new growth. Attached to the 
external surface of the sclerotic behind, is a lobulated mass of 
growth of a mottled colour. The several portions of the 
growth are found microscopically to consist of spindle-shaped 
cells. 

(Recorded in R.L.O.H. Reports, vol. vii, p. 277.) 

"No. 23. — The half of a shrunken eye with a mass of new 
growth attached to it. It was removed from a man aged 78, 
who had lost the sight in it 13 years before by spontaneous 
inflammation. ISTo further trouble was noticed in the eye until 
two years before excision, when it became irritable. Promi- 
nence of the eye had only been noticed by the patient for three 
weeks. The only parts of the globe recognisable are some wrinkled 
cornea and sclerotic, and some pigmented tissue at the front 
part of the specimen. The optic nerve has been cut more than 
an inch behind the eye, a considerable part of it is infiltrated 
with new growth, but the proximal end appears healthy. The 
tumour forms a firm lobulated mass measuring 4 cm. antero- 
posterior^ and 2"5 cm. vertically. It has evidently started 
from the interior of the globe, and is of a greyish colour on 
section, somewhat blood-stained. Microscopically, the tumour is 
found to consist of rather large spindle-shaped cells. The patient 
is reported to have died from " inflammation of the lungs and 
diarrhoea" two years after removal of the eye. 

(Recorded in R.L.O.H. Reports, vol. vii, p. 616, and vol. ix, 
p. UA 



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IN THE HOSPITAL MUSEUM. 35 

No. 24. — The lateral half of the left eye of a man aged 57. 
Three months previous to its excision he had received a blow 
on it from a clothes prop. He noticed nothing wrong with the 
sight until the last six months when it failed completely in the 
course of two or three weeks, and shortly after pain set in, and 
the tension became increased. The angle of the anterior 
chamber is seen to be closed by the apposition of the root of 
the iris to the periphery of the cornea. The growth started 
in the opposite half of the globe to that preserved, and only its 
apex, which protruded beyond the middle line, and which was 
cut off in making the section, is shown. It forms a large 
circular deeply pigmented mass lying in the centre of the 
globe, with the retina attached over one surface of it. The 
retina is everywhere detached from the choroid. The patient 
was alive and well two years and eight months after the removal 
of the eye. 

(Recorded in R.L.O.H. Reports, vol. xiii, p. 156.) 

No. 25. — The outer half of the left eye of a woman aged 70. 
A defect of sight in it was first noticed five months previous 
to its removal. The tension at the time of excision was normal. 
Springing from the lower and posterior part of the choroid is a 
large tumour of a white colour, which fills about two-thirds of 
the interior of the globe posterior to the lens. Where it starts 
from the choroid the growth has a broad base, it then becomes 
constricted, and afterwards expands into a rounded nodule, the 
size of a cherry. The vitreous is much shrunken ; the retina, 
which is attached to the apex of the growth, has been pushed in 
front of it, and is partially detached. The lens is in situ ; the 
anterior chamber is shallow, but its angle is not closed. Micro- 
scopical examination shows the growth to be a small round- 
celled leuco-sarcoma. The patient was alive and well two years 
after the removal of the eye. 

(Recorded in R.L.O.H. Reports, vol. xiii, p. 156.) 

No. 26. — The lower and outer fourth of an eyeball, and a 
thick section of it embedded in celloidine, mounted in separate 
cells. The eye was removed from a woman aged 59, who two 
years previously, had first noticed failure of sight, and for the 
last three months had had pain in it. Its tension at the 
time of excision was +2. A densely black growth is seen 

D 2 



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86 DESCRIPTIVE CATALOGUE OF SPECIMENS 

springing from the choroid, by a base which extends from the 
margin of the optic disc to a little in front of the equator. 
As it extends inwards, it becomes constricted into a narrow 
neck, and then expands into a rounded knob. The growth fills 
about one- third of the interior of the globe. Below the optic 
nerve, external to the sclerotic, is a small pigmented nodule. 
A pigmented line is seen in the sclerotic, connecting the intra 
and extraocular portions of the growth ; it is best shown in the 
thick section of the eye. It is in the position of the track of 
one of the long ciliary arteries. Microscopically the growth 
is found to be a round-celled melanotic sarcoma. The patient 
was alive two years after the operation. 

(Recorded in R.L.O.H. Reports, vol. xiii, p. 156.) 

Wo. 27. — Half an eyeball, and, protruding from it, a large 
mass of growth. It was removed from a man aged 76, who 
had noticed failure of sight in the eye for two years. The 
fun gating mass of growth had bled considerably, and the 
patient was in a very feeble state of health at the time of the 
operation ; he died immediately after it was finished, while still 
under the influence of the anaesthetic. The globe is of normal 
size ; the whole of its interior is filled with a mass of new 
growth of a soft consistency and brownish hue. The sclerotic 
is nowhere invaded by it. The whole cornea is absent, and 
passing through the globe, in the position normally occupied by 
it, is some new growth, which is of the same character as that 
in the interior of the globe. The growth expands externally into 
a large nodulated mass, having in it irregularly shaped cavities. 
Microscopical examination shows the tumour to be a round- 
celled sarcoma with a small amount of pigment in it. 

(Recorded in R.L.O.H. Reports, vol. xiii, p. 134.) 

No. 28. — The outer half of the right eye of a man aged 70 ; 
the sight of it had gradually failed for 12 months, and during 
the last two months it had become painful. The tension at 
the time of its removal was +1. In the posterior and outer 
part of the globe is a pyramidal-shaped, deeply pigmented, 
tumour, about the size of a large cherry stone, with a broad 
base, where it starts from the choroid. The angle of the 
anterior chamber is narrowed by apposition of the root of 



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IN THE HOSPITAL MUSEUM. 87 

the iris and the periphery of the cornea. The lens, which was 
cataractous, has a peculiar grey band passing horizontally 
through the nucleus. The vitreous is much shrunken, and 
the retina is extensively detached from the choroid. The patient 
was alive and well two years and one month after the removal 
of the eye. 

(Recorded in R.L.O.H. Reports, vol. xiii, p. 156.) 

No. 29. — The lateral half of an eye, together with a large 
extraocular growth. It was removed from a woman aged 85. 
The sight of the eye had commenced to fail four years previous 
to its excision ; in the last six months the eye had rapidly become 
prominent. The shape of the eye is considerably altered, one 
side of it being much flattened. The interior of the globe is filled 
with deeply pigmented new growth, which extends forwards into 
contact with the back of the cornea ; a small remnant of the 
lens with calcareous deposit in it can be seen. Posteriorly, 
there is a large gap in the sclerotic, through which the growth 
passes out and forms a large extraocular mass, which in its 
growth has pressed urjon and flattened one side of the globe. 
There is some pigmented new growth within the sheath of the 
optic nerve, and the nerve substance is much pressed on by it. 
Microscopical examination shows the tumour to be a round- 
celled melanotic sarcoma. The patient died five months after 
the operation. , 

(Recorded in R.L-.O.H. Reports, vol. xiii, p. 158.) 

/ 
No. 30. — The lateral half of the left eye of a man aged 52. 
Failure of sight and; occasional attacks of pain had commenced 
in it Lo months previous to its removal. A mass is seen grow- 
ing from the upper part of the choroid, and extending from 
the region of the ora s errata nearly up to the optic disc. It is 
thickest about the equator. The cut surface of it is unevenly 
pigmented. The retina is completely detaclied from the 
choroid, but adherent d)ver the surface of the growth. The lens 
and iris are in situ. Microscopically the tumour is seen, to be 
a round and spindle-celled melanotic sarcoma. 

No. 31. — A 1 portion of the outer half of the left eye of a man 
aged 49, who /had noticed failure of sight in it for six months. 



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38 DESCRIPTIVE CATALOGUE OF SPECIMENS 

Growing in the choroid is a partly pigmented tumour, which 
extends from close to the margin of the optic disc posteriorly, to 
a little in front of the equator anteriorly. Large vascular 
channels are seen coursing through it, at the seat of section., 
The tumour is apparently entirely confined beneath the elastic 
lamina. The retina is raised by the growth but is not detacbed. 
Microscopically the tumour is found to be a round-celled sar- 
coma. The patient was alive and well 22 months after the 
removal of the eye. 

(Recorded in R.L.O.H. Reports, vol. xiii, p. 158.) 

No. 32. — The two lateral halves of a right eye mounted in 
separate cells. It was removed from a man who a year pre- 
viously had, while out hunting, received a blow from a twig on 
it, which gave rise to some retinal haemorrhage. It was glau- 
comatous at the time of excision. In the outer half of the eye 
is seen a deeply pigmented growth about the size of a black- 
berry. Its base extends from the outer margin of the optic 
nerve to the equator of the globe. The growth has a constric- 
tion in it extending throughout its entire circumference near 
its base, so that it has somewhat the sharie of a mushroom. In 
the inner half of the eye the retina, which is much plicated, is 
seen passing through the centre of the glo^e, being completely 
detached from the choroid, and only adherent at the optic disc 
and ora serrata. The vitreous is exceedingly shrunken, and the 
retina appears to lie in contact with the back of the lens. Both 
lens and iris are displaced forwards, the anagle of the anterior 
chamber being closed by apposition of iris a,nd cornea. 

No. 33. — The two lateral halves of the left eye of a man aged 
25, mounted in separate cells. He had had an injury to it from 
a twig 15 years previously. Failure of •, sight had only been 
noticed six or eight weeks. The tension at the time of exci- 
sion was increased. Springing from the choroid by a broad base 
in the centre of the outer half of the glojbe is a brown spongy 
mass the size of a small cherry. It has a constriction in it near 
its base. The retina, which is shown in the inner half of the eyes 
is completely detached from the choroid, and retains adhesions 
only at the optic disc and ora serrata. It is apparently in con- 
tact with the back of the lens. The lens and iris a?e both much 



\ 

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IN THE HOSPITAL MUSEUM. 



39 



displaced forwards, the angle of the anterior chamber being 
closed by apportion of the root of the iris to the cornea. Micro- 
scopical examination shows the growth to be a round-celled 
melanotic sarjcoma. The patient was alive and well 17 months 
after the remjoval of the eye. 

(Recorded in R.L.O.H. Reports, vol. xiii, p. 160.) 

34 — Theupper and lower halves of an eyeball, the history of 
which is no^nown. They are mounted in one cell, one showing 
the outer s in a the other the inner surface. The interior of the 
glo'be is completely filled with a mass of deeply pigmented new 
growth, wjiich protrudes forwards as a fungating mass, ex- 
ternal to t\e o-lote in the region of the cornea, which structure 
has been Entirely destroyed. The lens is absent. Posteriorly 
on the jfoiter side, the growth has penetrated the sclerotic 
between the insertioi of the two oblique muscles. The optic 
nerve hJ as been cut loh(, the part nearest the eye being invaded 
^y pigmented growth, vhich does not extend as far as its cut 
extreruiW. • 

\ ) 

JSTo. ;35.— IVhe outer Aalf of the left eye of a woman, aged 57. 
Five yeWs pre\vious t> its removal she had had a blow on it 
from a mst. Aft fetitA- *me of excision there was a large corneal 
abscess* ar ,d thle tension was +2. Daring removal the cornea 
perforatW^ the lens escaped, and the eye became partially 
collapsed^ The cornea is seen to be wrinkled, yellow, and 
infiltrated)^ The refcnia is detached from the choroid, remain- 
ing adherens only at the ora serrata and optic disc ; it is 
much folded and drawn forwards. The choroid over about 
two-thirds of $ts extent is uniformly thickened by a melanotic 
new growth,' anfd- measures 2 mm. in width. At the lower part 
of the globeVin the position at which one of the long ciliary 
arteries per/ ora tes the sclerotic, is a small extraocular nodule 
of pigmenf ec [ growth. New growth is also seen between the 
optic nery e an a its dural sheath. Between the choroid and 
sclerotic at the upper part of the globe is some recent blood clot. 
Microscolp:L Ca l examination shows that the growth is a mixed 
round a^d spindle-celled melanotic sarcoma. Fourteen months 
after J$he removal of the eye the patient was alive and well. 

(Recorded in R.L.O.H. Reports, vol. xiii, p. 160.) 



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40 DESCRIPTIVE CATALOGUE OF SPECIMENS 

No. 36.— A ring section cut from the centre of the left eye of 
a woman, aged 59. She had noticed failure off vision in the 
outer part of her field for six months, and ophtftalmoscopicaJIy 
a hemispherical detachment of the retina could ie seen, which 
appeared to have behind it a solid mass. A grey coloured growth 
is seen springing from the choroid at a point ajbout midway 
between the ora serrata and the optic disc. It measures about 
10 mm. across. The retina passes closely over tie surface of 
the growth, and is nowhere detached from the /SiiQroid. The 
angle of the anterior chamber is narrow, bilt n pt closed. 
Microscopically the growth is found to be a spindle-celled 
sarcoma. 

No. 37.— The lateral half of the right eye of a maW aged 64. 
He had noticed failure of sight in it for sevjn months. \Tlie ten- 
sion at the time of its removal was increased. A largeV row * n > 
which occupies rather more than a thirl of the interiof of the 
globe, springs by a base from the upjer part of the d Q0 £ci4 
and extends from the hindermost jf the cf V ^^■^fec'esses ' 
backwards to within about 8 mm. <z the optic/ nM^e. Its 
section is of a greyish colour, with her and there/^ight patches. 
There is a marked indentation in the amour posteriority The 
retina is detached from the choroid. TheposAcelrior surface of 
the lens is pressed upon by the tumour ^d tfye angle jo-f -^he 
anterior chamber is narrowed. Microscopically the /growth 
is seen to be a melanotic spindle-celled sarcoma/ Eight 
months after the removal of the eye the patient /was alive 
and well. i 

(Recorded in R.L.O.H. Reports, vol. xiii, p. 16^0 

\' 

No. 38.— The inner half of the left eye of ^ man, aged 35. 

He had noticed a defect in the sight of it Jf or eigfe months, but 
it had only become painful a week previous to itsV em °val. A 
deeply pigmented tumour is seen growing from the loiter part of 
the choroid, by a base which extends from! the hinderrfcost of the 
ciliary processes to the margin of the opt,ic disc. It jf*Us about 
half the interior of the globe. The section, of the growth shows 
it to have a peculiar foliated arrangement, resembling Ifche con- 
volutions of the brain. The retina is pushed in front \P^ the 
growth, and detached elsewhere from the choroid. The 



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Fig. 13.— Specimen 38, showing the peculiar foliated arrangement of the 

tumour at the seat of section. 



has fallen out of the specimen in the process of mounting. 
Microscopically the growth is found to be a mixed round and 
spindle-celled sarcoma. The patient was alive and well seven 
months after vhe removal of the eye. 

(Recorded in R.L.O.H. Reports, vol. xiii, p. 162.) 

No. 39.— The lateral half of the left eye of a milkman, aged 
50, who dated the defect of sight in it from five months previous 
to its removal, when he received a blow on it from a cow's tail. A 
week before excision the eye became painful and glaucomatous. 
Filling three-fourths of the interior of the globe behind the lens 
is a buff-coloured mass of new growth of soft uniform consis- 
tency. It springs by a base 15 mm. wide from the posterior 
part of the choroid around the optic disc ; it then narrows into a 
thin neck, and again expands into a large circular mass. No 
trace of the retina can be distinguished in the specimen ; blood 
clots fill the space between the tumour and the lens, which, 
together with the iris, is much pressed forwards. The anterior 
chamber is very shallow, and contains blood clote^difo^g^c.. 
ally the growth is seen to be c.omnnspH ^f ™„i „~j _i 



42 DESCRIPTIVE CATALOGUE OP SPECIMENS 

cells. It is exceedingly vascular ; in places the vessels have 
well defined walls, in others the structure of the growth 
resembles nevoid tissue. It may be best described as a nasvo- 
sarcoma. 

No. 40. — The lower half of an eyeball with a large mass of 
extraocular growth. It was removed from a man aged 46, who 
first noticed failure of sight in the eye 18 months previously. 
During the last six months it had been inflamed, and had 
gradually increased in size. Starting from the choroid and 
filling half the interior of the globe behind the lens is a mass of 
deeply pigmented new growth. It passes through the sclerotic 
about its equator, and forms a large mass external to the globe, 
which presses upon but does not invade the optic nerve. The 
vitreous is much shrunken. The retina is detached from the 
choroid. The angle of the anterior chamber is much narrowed 
by adhesion of the root of the iris to the cornea. In the choroid, 
in the outer half of the globe, there are numerous scattered small 
circular black patches. There was a large recurrence of the 
growth in the orbit six months later. 

No. 41. — The inner half of the left eye of a woman, aged 55. 
Failure of sight had been noticed in it for about three months 
previous to its removal. At the time of excision the tension 
was increased and the eye painful. The anterior chamber is 
exceedingly shallow, and its angle is closed by apposition of the 
root of the iris to the cornea. Springing from the choroid by 
a base that extends from the equator to the margin of the 
optic disc, is a deeply pigmented growth, which has a constric- 
tion in it, and then expands into a rounded knob, that reaches to 
about the middle line of the globe. The retina is completely 
detached from the choroid, from the optic disc up to the ora 
serrata, but is attached to the apex of the growth. 

Sub series (F). — Starting in the Retina. 

Tumours of the retina may be either cystic or solid. 
Cystic growths of the retina are most commonly met with 
in eyes which have been blind for some years, and in 
which the retina is detached (Nos. 1, 2, 3, and 4). In the 



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IN THE HOSPITAL MUSEUM. 43 

retinae in which they form there is considerable increase of 
the fibrous tissue and atrophy of the nervous elements ; 
they are also cedematous, the tissue of which they are 
composed being much spaced out. It is probable that 
this oedema of the retina is due to atrophic changes in the 
nerve, causing constriction of the thin- walled central veins 
and retardation in the exit through it of the blood. The 
cysts are the result of the oedema, the larger spaces 
breaking into one another, and the thin-walled cavities so 
formed readily expanding into spaces visible to the naked 
eye. Several cysts are sometimes met with in one retina 
(Nos. 1, 2, and 3) ; they generally protrude from its outer 
wall (Nos. 1, 2, and 3), but may be located in its centre 
(No. 4). 

By far the commonest form of solid grow T th starting 
in the retina is what is known as glioma ; in the recent 
state and in an early stage of its growth it is of 
pingish-grey colour, and has a brain-like consistency. In 
the process of hardening it becomes more opaque, and 
assumes a yellowish hue. It is a rapidly growing form of 
tumour, and its tissue rapidly degenerates ; the first sign 
of degeneration can be detected in microscopical sections 
by the nuclei of the cells staining less readily with log- 
wood, so that the stained specimen presents a patchy 
appearance. 

Later on signs of fatty degeneration can be distin- 
guished with the naked eye as opaque yellowish- white 
markings (Nos. 8, 10, 11, 16, 17, and 18). In some of the 
growths calcareous changes are found, the chalky patches 
being rendered evident by their grittiness and extreme 
whiteness (No. 10). When the growth is very degenerate 
it becomes quite flocculent in consistency (Nos. 5, 6, 12, 
13, and 17). 

In some eyes glioma starts as a localised tumour in one 
portion of the retina (Nos. 8, 9, and 20), in others it is 
more diffuse, beginning as a uniform thickening over a 
wide area (Nos. 7, 10, and 16). Occasionally it begins in 



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44 DESCRIPTIVE CATALOGUE OF SPECIMENS 

several different places at the same time, giving rise to a 
nodulated condition of the surface of the retina (Nos. 15 
and 21). A glioma starting in the retina may commence 
either in its inner or its outer layers ; if in the former it 
tends to grow inwards towards the vitreous chamber, 
glioma endophytum (Nos. 6, 9, 11, and 20) ; if in the latter, 
outwards between the retina and choroid, glioma exophytum 
(Nos. 8, 18, 19, and 21). In glioma endophytum little 
separate isolated nodules of growth often form in the 
vitreous chamber (Nos. 8, 12, 14, 16, and 20). These 
nodules previous to excision can be seen with the ophthal- 
moscope. Sometimes they are mobile. The growth when 
it springs from the inner surface of the retina, appears as 
a ragged, nodulated mass far back in the eye, and being 
in front of the retinal vessels conceals them from view. 
Occasionally large haemorrhages in the vitreous may be 
associated with this form of growth (No. 20). 

When the tumour grows from the outer surface of the 
retina, that structure becomes pushed in front of it and 
detached from the choroid, the vitreous shrinking. In 
such a case, clinically, the smooth surface of the retina, 
rendered yellow and opaque by the growth behind, is seen 
with its blood-vessels far forwards immediately posterior 
to the lens. The space formed by the detachment of the 
retina from the choroid is often greater than that occupied 
by the growth, and is filled up with serous fluid (Nos. 8, 
15, 18, and 21). When the outer surface of the retina is 
involved by a gliomatous tumour the membrane of Bruch 
may become perforated and the growth extend into the 
choroid (Nos. 6, 10, and 17). It may even infiltrate 
through the sclerotic and form an extraocular mass (No. 
10 and Series III, Subseries C, No. 10). A more frequent 
way for glioma of the retina to find exit from the eye is 
along the track of the optic nerve. Growth in the nerve 
can be recognised by the naked eye, for not only does the 
nerve become enlarged, but it presents an unnatural grey 
colour on section (Nos. 6, 7, 9, 10, 15, and 17). Micro- 



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IN THE HOSPITAL MUSEUM. 45 

scopically the glioma cells are seen to replace the nerve 
fibres, leaving the trabecular network of fibrous tissue 
uninvolved. Not uncommonly gliomatous growth finds 
its way into the space between the pial and dural sheaths 
of the nerve, along which it extends backward. 

As a glioma of the retina continues to grow, the lens 
and iris become pressed forwards and the anterior chamber 
shallowed, its angle being closed by the apposition of the 
root of the iris to the cornea (Nos. 7, 13, 15, 17, and 18). 
Increase of tension then ensues. The cornea and sclerotic 
in young eyes being very elastic, readily expands, and 
the whole globe becomes enlarged (Nos. 6, 10, and 17), 
the condition known as buphthalmos sometimes being -pro-^" 
duced (Series III, Subseries C, No. 10), and^V other times 
a staphyloma at the sclero-corneal margin- (No. 13). 

If the eye is not excised the^growth will extend into 
the anterior chamber (Seriejs-IfiC Subseries C, No. 10), per- 
forate the cornea, and form a large fungating mass ante- 
riorly, to which condition the termed fungus hcematoides 
was formerly applied. 

Glioma of the retina is a form of growth which only 
occurs in childhood, never after the 11th year, and usually 
in infancy. There is, however, one exceptional specimen 
of a solid growth of the retina in this collection occurring 
in the eye of a woman aged 65 ; its microscopical charac- 
ters presented certain • decided differences to those of an 
ordinary glioma of the retina (No. 22). 

No. 1.— The lateral half of the left eye removed from a 
woman, aged 41. Fourteen years previous to excision it had 
l?een str del: with a fist, after which it went blind, and had 
remained so ever since. The last five months it had become 
painful. The pupil is widely dilated ; there is some ectropion 
of the uveal pigment. The anterior chamber is of good depth, 
but its angle is narrowed by the adhesion of the root of the 
iris to the periphery of the cornea. The lens is in situ and the 
vitreous is much shrunken. The retina is completely detached 
from the optic disc up to the ora serrata ; it passes through the 



( 



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Fig. 14. — Specimen 1, showing cysts protruding from the outer surface of 

the detached retina. 

centre of the globe as a thin, round cord which expands ante- 
riorly. From the posterior part of the detached retina two 
thin-walled transparent cysts project ; the largest is about the 
size of a currant. When the eye was first opened they contained 
an opaque gelatinous substance. The choroid is thin, but 
otherwise healthy. 

(Recorded in R.L.O.H. Reports, vol. xiii, p. 68.) 

No. 2. — The outer half of the right eye from a man, aged 30. 
It had been blind for seven years as the result of inflammation. 
A week before excision he injured it with his finger, and it had 
become painful. The anterior chamber is of a good depth, and 
its angle is open. The lens is of a uniform white colour, and 
of stony hardness throughout. The vitreous is much shrunken. 
The retina is detached from the ora serrata up to the optic disc. 
Protruding from its outer surface are several small thin-walled 
cysts, one of them is of a brownish colour; in the choroid 
opposite to it there is a patch of atrophy and considerable dis- 
turbance of the pigment epithelium. 

(Recorded in R.L.O.H. Reports, vol. ifflf fr.Wpg 



IN THE HOSPITAL MUSEUM. 47 

N 0> 3. — The lateral half of the right eye of a man, aged 48. 
Twenty years previous to excision he received a blow on it from 
a fist ; a cataract formed which, two years later, was operated 
on. He had no sight in the eye after the operation. The last 
eight weeks it had become painful. There is a staphyloma 
posteriorly at the inner side of the optic disc where there is 
considerable atrophy of the choroid. The optic disc is markedly 
cupped. The iris is much shrunken, its root is adherent to the 
periphery of the cornea, and there is marked ectropion of the 
uveal pigment. The retina is shrunken and detached every- 
where from the choroid ; it only retains adhesions to the optic 
disc and to the ora serrata on one side of the specimen ; pro- 
truding from its outer surface are two thin-walled cysts. 

No. 4. — The outer half of the left eye of a man, aged 32. 
Thirteen years previous to its removal it had been injured with 
a piece of gun-cap ; eight years later it became inflamed, and 
the sight failed completely. The last month it had been again 
inflamed and painful. The lens is absent. There are some 
blood-clots in the anterior chamber about the iris and in the 
anterior part of the vitreous. The vitreous is much shrunken. 
The retina is detached from the choroid, from the optic disc up 
to the ora serrata ; on one side there is a large oval cyst in it 
which projects as much towards the vitreous chamber as 
towards the subretinal space. Some blood-clots lie on the 
inner surface of the choroid. 

(Recorded in R.L.O.H. Reports, vol, xiii, p. 68.) 

No. 5. — The lateral half of the left eye of a boy, aged 
3 J. Seven months previous to excision something white was 
first noticed in his eye by his parents. The specimen is not 
well preserved and is somewhat flattened from before back- 
wards. A tumour of a flocculent consistency and greyish 
colour is seen growing from the inner surface of the retina 
and nearly filling the vitreous chamber. Microscopically it 
presents the typical appearances of a gliomatous growth. The 
patient was seen 19 years after excision, and no recurrence of 
the growth had taken place. 
. (Recorded in R.L.O.H. Reports, vol. xiii, p. 20.) 



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48 DESCRIPTIVE CATALOGUE OF SPECIMENS 

i 

No. 6. — The lateral half of the left eye and portions of the 
left optic nerve from a child, aged 2 years. When 6 months 
old she was brought to the hospital and glioma of the retina 
was diagnosed. The globe is enlarged and the sclerotic 
thinned. Springing from the inner surface of the retina, and 
filling a great portion of the vitreous chamber, is a flocculent, 
grey-coloured growth. Posteriorly it has invaded the choroid, 
causing considerable thickening of it. The optic nerve is also 
involved ; two sections of it are preserved, one taken from close 
to the eyeball and one some little distance further back ; the 
former is markedly larger than the latter. Three weeks after 
excision the child died with recurrences over the left brow and 
in the mouth. 

(Recorded in R.L.O.H. Reports, vol. xiii, p. 26.) 

No. 7.— The outer half of the left eye of a child, aged 4£.' 
At the time of excision it was quite blind and the tension was 
slightly raised. A new growth of a greyish colour, with a 
granular surface, involving the retina, extends from a point 
close to the optic disc as far forwards as the ora serrata. Its 
inner margin is slightly within the median line, and its 
anterior surface is in contact with the back of the lens. The 
upper part of the retina can be seen wrinkled, detached, and 
uninvolved by growth. Springing from the optic disc is a 
small nodule of growth which, unlike the larger mass, is 
growing into the vitreous. Four years and seven months 
after the operation the child was reported to be alive and well. 

(Recorded in R.L.O.H. Reports, vol. xiii, p. 30.) 

No. 8. — The lateral halves of the two eyes of a boy, aged 
5 months at the time of excision of the right, and 3 years and 
5 months at the time of excision of the left. A month pre- 
vious to excision the mother noticed a white appearance in the 
right. After its removal his health improved; and it was not 
until three years later that she noticed a similar appearance 
beginning in the left eye. The right eye is considerably 
smaller than the left, and in it the lens and iris are pressed 
forwards, so that the anterior chamber is almost obliterated. 
The vitreous is very shrunken and the retina is complete ! y 



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IN THE HOSPITAL MUSEUM. 49 

detached from the ora serrata up to the optic disc ; anteriorly 
it is apparently in contact with the back of the lens. From the 
outer surface of the detached retina on one side, sj)rings a 
greyish-yellow coloured growth speckled with white dots. 
Between the detached retina and the choroid is some grey 
gelatinous substance. In the left eye on the inner surface of 
the retina are numerous round, grey, nocculent nodules of new 
growth. The retina is also raised in places by masses of new 
growth on its outer surface. A portion of the retina which 
has been cut away allows of this being seen. The growth does 
not come anywhere near the optic disc. 

No. 9. — The lateral half of the left eye of a girl, aged 14 
months at the time of its removal. Her right eye had been 
excised when she was 3 months old for a glioma of the retina. 
The vitreous chamber is filled for about a third of its extent by 
new growth which is springing from the inner surface of the 
retina. The papilla of the optic nerve is surrounded and in- 
volved by the growth. Three years after the enucleation of the 
second eye the patient was alive and well. 

(Recorded in R.L.O.H. Reports, vol xiii, p. 34.) 

No. 10. — The outer half of the right eye of a boy, aged 2 ; a 
growth in it was first noticed a year previous to excision. Tlie 
eyeball is considerably enlarged, a new growth filling about two- 
thirds of the cavity of the globe behind the lens, and almost 
completely replacing the retina. It is in contact with the back 
of the lens anteriorly and invades the choroid posteriorly. 
The section of the growth presents a very mottled grey and 
white appearance. In the anterior part there are numerous 
white patches, due to calcareous deposit. Microscopically the 
optic nerve was extensively invaded by tumour cells. A 
recurrence of the growth occurred in the orbit less than 
three months after excision, and eight months later the 
child died. 

(Recorded in R.L.O.H. Reports, vol. xiii, p. 32.) 

No. 11. — The lateral half of the right eye of a child, aged 6 ; 
it had been blind for fonr months previous to excision, Fillino- 
nearly half the vitreous chamber is a yellowish-white coloured 



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50 DESCRIPTIVE CATALOGUE OF SPECIMENS 

tumour springing from the inner surface of the upper part of 
the retina. 

(Recorded in R.L.O.H. Reports, vol. xiii, p. 26.) 

No. 12. — The lateral half of the right eye of a girl, aged 6 ; 
something was first noticed to be wrong with the eye seven 
months previous to excision. The lens is considerably flattened 
antero-posteriorly, but was clear in the recent state. The 
retina is indistinguishable, being entirely involved in a friable 
yellowish-grey coloured new growth. The vitreous is much 
shrunken, and has some nodules of new growth in it immediately 
behind the lens. The child died about three years after excision 
of the eye. 

(Recorded in R.L.O.H. Reports, vol. xiii, p. 28.) 

No. 13. — The lateral half of the left eye of a girl, aged 6 ; 
a year previous to excision she fell and struck the eye, after 
which the sight of it was first noticed to be defective. The 
last few days it had become painful. The sclerotic at the upper 
corneal margin is staphylomatous. The staphyloma does not 
involve the ciliary body, but ends posteriorly at the ciliary 
processes. The whole of the inner surface of the bulging part 
is lined by the atrophied root of the iris. The angle of the 
anterior chamber on both sides of the specimen is closed. The 
lens has dropped out ol the specimen in the course of its pre- 
paration. A nodular growth of friable consistency occupies 
about half the vitreous chamber, replacing in great part the 
retina. There are patches of new growth on the inner surface 
of the choroid. 

(Recorded in R.L.O.H. Reports, vol. xiii, p. 28.) 

No. 14. — A portion of vitreous from the eye of a boy, aged 3, 
which was removed for glioma of the retina. Previous to re- 
moval, floating white masses could be seen in the vitreous and 
also small white dots which stood out plainly against the red 
fundus reflex. These white dots, which are nodules of 
gliomatous growth, are shown in the specimen, the largest 
being the size of a pin's head and the smallest ouly just visible 
to the naked eye. Three years after excision the child was 
stated to be alive and well. 

(Reported in R.L.O.H. Reports, vol. xiii, p. 36.) 



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IN THE HOSPITAL MUSEUM. 51 

No. 15. — The inner half of the right eye of a boy, aged 7, 
which was quite blind, and with the tension increased, at 
the time of the excision. The angle of the anterior chamber is 
closed by adhesion of the root of the iris to the periphery of 
the cornea. There is some ectropion of the uveal pigment at 
its pupillary margin. The vitreous is shrunken and the retina 
detached from the optic disc up to the ora serrata; it is much 
thickened with nodules of a grey coloured new growth. The 
portion of the optic nerve left attached to the globe is much 
enlarged, and on section has a greyish hue. Microscopically 
the nerve substance is seen to be in great part replaced by 
glioma cells ; there is also a mass of similar cells between the 
pial and clural sheaths. The patient died 10 months after the 
removal of the eye, with a recurrence in the orbit and growths 
in the brain, neck, and left eye. 

No. 16.— The outer half of the right eye of a boy, aged 
6 years. Ophthalmosco|3ically a white mass was seen behind 
the lens, and also several small floating nodules. The retina 
in its lower two- thirds is considerably thickened by a new 
growth of a mottled., greyish- white appearance on section. 
It is rucked and folded, but not completely detached. In the 
vitreous immediately behind the lens is a yellow, opaque 
nodule. In parts the growth seems to have sprung chiefly 
from the outer surface of the retina, in others it seems to 
thicken it uniformly. 

No. 17. — The inner half of the left eye of a boy, aged 2. 
His mother stated that it had always appeared different to his 
other eye, but that the last fortnight it had become red. The 
eyeball is enlarged, its antero-posterior diameter being much 
increased. The sclerotic is thinned anteriorly. The root of the 
iris is adherent to the periphery of the cornea at the seat of 
section for some considerable distance. There is a large amount 
of blood clot in the anterior chamber. The whole interior of 
the globe posterior to the lens is filled with new growth which 
has completely replaced the retina. The anterior part of this 
growth is very flocculent and mixed with blood clot. Posteriorly 
it is of a mottled greyish-white colour, and is invading th.3 
VOL. XIV. E 



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52 DESCRIPTIVE CATALOGUE OF SPECIMENS 

choroid and inner layers of the sclerotic. The portion of the 
optic nerve left attached to the globe is grey in colour and 
enlarged. The patient died three months after excision of 
the eye. 

"No. 18.— The lateral halves of the two eyes of a boy, aged 
1 year and 2 months ; they are both mounted in one cell. Six 
weeks after he was born his mother stated that she noticed that 
his left eye (the shrunken one) seemed to have a hole in it. 
Previously it had been quite well, and at no time was there any 
discharge from the eyes. The left eye gradually shrank. When 
he was eight months old she found his right eye was defective. 
The left eye is a small shrunken globe, the cornea and sclerotic 
are much thickened, no iris can be distinguished, the lens is 
absent, the whole interior of the globe is filled with a grey 
coloured growth, the microscopical appearances of which are 
characteristic of glioma. The right eye is of normal size, the 
retina is completely detached and apparently in contact with 
the posterior surface of the lens, from it grows an irregular 
grey coloured mass with white patches in it. This mass is 
not in contact with the cornea. The anterior chamber is very 
shallow, its angle being closed. 

Ho. 19. — The lateral halves of the two eyes of a patient, 
aged 7 months. Three weeks before excision the mother first 
noticed something wrong with the patient's right eye. Her 
statement was that it looked transparent. Four or five days later 
she saw a similar appearance in the left. The right eye (a) 
Was opened whilst it was fresh and subsequently hardened. 
In it the retina is detached and in contact with the posterior 
surface of the lens. Growing from it, and filling nearly the 
whole of the interior of the globe behind the lens, is a soft 
grey mass. The left eye (6) was hardened before it was 
opened ; in it the retina is also detached and apparently in 
close contact with the lens> The new growth, of a grey colour 
on its Outer surface, is not so extensive as in the right eye. 
Microscopically the growth in each eve presents the typical 
appearances of glioma retince ; the optic nerve is seen to be 
affected up to, but not beyond, the lamina cribosa. Three years 



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IN THE HOSPITAL MUSEUM. Do 

and a half later the child was in excellent health, and there 
had been no return of the growth. 

No. 20. — The outer half of the right eye of a girl, aged 4 
years. Three weeks previous to excision, the mother first 
noticed something white in it. On examination the child was 
found to have no perception of light with that eye, the tension 
was increased, and several oscillating nodules were seen 
ophthalmoscopically behind the lens, in addition to a white 
mass and a large blood clot. Growing from the inner surface 
of the retina is an irregularly grey coloured mass which, 
microscopically, is seen to be composed of characteristic glioma 
cells. This new growth has apparently started from the innei 
nuclear layer. There are several small round secondary 
nodules of growth, composed of the same shaped cells, in the 
vitreous. The retina is everywhere in situ; on its inner sur- 
face at the lower part is a dark coloured hemorrhage. Three 
years and three months later there had been no recurrence of 
the growth, and the child was quite well. 

No. 21. — The inner half of the left eye of a boy, aged 3 
years* His mother had noticed that his right eye had turned 
in ever since he was born. She thought it had been getting 
larger for one month ; it had been blind one week. The 
whole retina is detached from the optic disc up to the ora 
serrata, On its outer surface are numerous little nodules of 
growth. Its inner surface appears to be in contact with the 
back of the lens. The inner surface of the choroid is speckled 
with dots of dark pigment. Microscopically the growth is seen 
to be a glioma. Three years and four months after excision 
there had been no return of the growth, and the child was in 
good health. 

No. 22.— A thick section from the centre of the right eye 
of a woman, aged 65. The specimen is divided into two 
halves. Four years previous to its removal she first noticed 
pain and failure of sight in it. The pain had become very 
acute during the last week; at the time of excision thn 
T. was +3, and she could not tell light from dark with it, 
The iris and ciliary body have become somewhat displaced 

E 2 



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51 DESCRIPTIVE CATALOGUE OF SPECIMEN'S 

backwards in the preparation of the specimen. The whole 
interior of the globe posterior to the lens has become filled with 
a mass of fawn-coloured new growth, it Is of a soft, flocculenfc 
consistency, and has some small patches of haemorrhage in it. 
It has entirely replaced the retina and vitreous. Micro- 
scopically the vascular supply is seen to be derived from vessels 
which radiate from the optic disc ; it is everywhere traversed by 
vascular channels with thin walls, arranged radially, around 
which are nucleated cells, mostly very degenerate. 

(Recorded in the Trans. Ophth. Soc, vol. xii, p. 165.) 

Sub series (G). Starting in the Optic Nerve, 

Tumours of the optic nerve are of rare occurrence, but 
are very various in their microscopical characters ; some 
have been described as sarcomata, some as myxomata, and 
others as gliomata. They may arise in the dural or pial 
sheaths, or in the nerve itself. The only one contained 
in this collection probably started in the pial sheath, or 
in the loose tissue between it and the dural sheath, the 
nerve being only secondarily involved. 

The outer half of an eyeball with a tumour growing from 
the optic nerve attached to it. It was removed from a boy, 
aged 12. Two months previous to its removal he first noticed 
that his left eye was larger than his right. It gradually 
increased in size, and his sight gradually failed. Previous to 
excision the left eye was found to be proptosed, being displaced 
forwards and downwards ; its movements were good. A hard 
mass could be felt at the upper and inner part of the orbit 
extending backwards. The optic disc was white, its margin 
blurred, and the retinal veins large and tortuous. The lens 
has fallen out of the eye, and its tunics have become some- 
what displaced in the preparation of the specimen. There are 
no pathological changes in it. Behind the globe in the sheath 
of the optic nerve is a tumour extending back from the sclerotic 
a distance of 23 mm. It is irregularly pear shaped, with the 
smaller end forwards, and measures in its widest diameter 
18' 5 mm. The cut section of the growth shows the nerve 
passing through it. There is a fusiform swelling of it, which 



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IN THE HOSPITAL MUSEUM. 55 

begins close to the papilla, and increases rapidly. It is 
widest about 9 mm. from the sclerotic, where it measures 
105 mm. vertically. It narrows down again to the point 
where it is divided, but it is there of a greater diameter than 
normal. Between the dural sheath and the nerve is a new 
growth with a somewhat speckled surface. It appears to be 
intimately connected with the nerve, and only loosely so with 
the sheath. Though surrounding the nerve completely, the 
greater part of it is situated on its upper surface. Micro- 
scopically the growth is seen to be a sarcoma of loose 
connective tissue type, which in parts is undergoing myxo- 
matous degeneration. 

(Recorded in R.L.O.H. Reports, vol. xii, p. 1.) 



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56 



ON THE IMMEDIATE AND REMOTE RESULTS OF CATARACT 
EXTRACTION. 

By 0. Deyereux Marshall, Curator. 

As a good deal of confusion exists in the minds of 
many people with regard to the result obtained after the 
operation of extraction of senile cataract in spite of the 
great amount of literature that exists on the subject, I 
shall endeavour in the following pages to discuss the 
matter and to bring forward a record of the cases that 
have been treated at the Royal London Ophthalmic 
Hospital for five years, from 1889 to 1893. 

I have chosen these years for investigation for the 
purpose of bringing our knowledge well up to date, and 
also because antiseptic agents have been rigidly employed ; 
now these have had almost as marked an effect in 
ophthalmic as in general surgery, notwithstanding the 
special difficulty that one has to contend with in disin- 
fecting the conjunctival sac and rendering the eye and 
the surrounding parts aseptic, owing to the delicate 
structures met with. There is, however, one point of the 
greatest importance in ophthalmic surgery, and one which 
perhaps more than any other external condition governs 
the results, and that is the care which is taken in avoiding 
the infectipn of the eye by any instruments which are used. 

Among the patients upon whom we have to operate, 
there are many unfavourable conditions to deal with. 

In the first place they are most of them old and their 
tissues lack that vitality which so greatly favours the 
repair of wounded and damaged parts. Many others 
have some definite and organic affection such as albumi- 
nuria, or diabetes, and this is a matter of no slight im- 
portance when considering the desirability of performing 
a surgical operation. See Table VII. 

In the second place we have to operate upon an organ 



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RESULTS OF CATARACT EXTRACTION. 57 

which cannot be considered to be in a healthy condition. 
The criterion of health of the crystalline lens is its 
transparency, therefore when the lens is opaque it shows 
that it has been subjected to processes which have 
materially affected its nutrition, and although the other 
structures of the eye do not show it in the same way, yet 
they have been exposed to the same conditions which 
have led to the production of cataract. 

In comparing the results obtained in recent years with 
those of the past, we must remember that a large number 
of cases can now be operated upon with greater or less 
success which in the pre-antiseptic days would have been 
considered unfit for surgical interference. Many eyes 
have their lenses removed which are well known to have 
serious diseases quite apart from senile cataract., but the 
risk of suppuration and other untoward events super- 
vening becomes so reduced, that one is justified in under- 
taking a serious operation with a fair prospect of 
materially benefiting the patient, although it is known 
there is no possibility of restoring the vision to anything 
like the normal standard ; therefore the percentage of 
successes is considerably lowered by taking such cases 
into consideration. 

Before proceeding further it may be well to state 
briefly the usual method of preparing a patient and the 
means adopted before, during, and alter the operation in 
order to prevent infection from without. 

I shall here only mention the special points connected 
with the eye, the general examination and preparation of 
the patient being precisely the same as that adopted 
previous to the performance of any surgical operation. 
The lids and parts around the eye are carefully washed 
with soap and hot water overnight, and then a pad which 
has been wrung out in a 1/4000 solution of the per chloride 
of mercury is applied. On removing this the next morn- 
ing one is able to obtain a good idea as to the state of 
the conjunctiva ; if the lids be gummed together th 



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58 ON THE IMMEDIATE AND REMOTE 

tion is deferred until a more satisfactory state of things is 
obtained. If, however, there is nothing to contraindicate 
the performance of the operation the eye is ansesthetised 
with a 2 per cent, solution of freshly prepared cocaine and 
the conjunctival sac is washed out with a good stream of 
either warm boracic or perchloride lotion. The instru- 
ments are boiled before being used and kept in carbolic 
acid lotion 1 — 40. 

After the operation both eyes are, as a rule, closed for 
a day or two and tied up with pads of Gamgee tissue 
made of the double cyanide wool. The operated eye is 
kept bandaged for about a week, and after that dark 
goggles are worn. 

Most of the cases recorded here have had iridectomy 
done at the time of the extraction. Some have had a 
preliminary iridectomy performed a few weeks before the 
removal of the lens, while others have had no iridectomy 
at all. The lens capsule has usually been opened with 
the cystotome but occasionally the anterior capsule has 
been torn away with Forster's forceps, while in others the 
capsule has been opened by a peripheral section with a 
Graefe's knife and the face of the capsule has remained 
intact. The sections were almost without exception 
made upwards, and in the majority of cases a conjunctival 
flap was cut. 

Cases which do well remain in the hospital about two 
weeks, and what is indicated in the tables by the <k im- 
mediate vision 1 ' is the vision obtained just before the 
patient leaves. 

The remote vision is taken at a variable time after the 
operation, seldom less than 6 — 8 weeks, and often not 
until several months have elapsed, I am sorry that so 
many blanks appear in this column, but numbers of people 
come from a considerable distance for the operation and 
then returning home, get tested for glasses elsewhere, so 
that we do not again see them, and it is practically im- 
possible to obtain the ultimate results of the^e operations. 



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RESULTS OP CATARACT EXTRACTION. 59 

This is unfortunate, for everyone knows how often the 
vision improves during the first few months after extrac- 
tion ; so that probably there are many cases here recorded 
with very indifferent li immediate vision," who in. reality 
are going about and seeing quite well. The converse can 
hardly be said to hold, viz., when the vision deteriorates, 
&c, for as a rule these palients return for advice and 
then defective vision is noted, and this again tends to 
lower the percentage of successful cases. 

I have used my utmost endeavour to get the remote 
visions in all cases, and have written to those whose 
visions have not been recorded, and thus have been 
enabled to see and test many people who had never been 
to the hospital since the extraction. I found that almost 
without exception the people who had not been up, had 
quite good vision, and I hardly saw a patient whose eye 
had undergone any marked sign ot degeneration ; this 
again showed that most of the unsuccessful cases came 
up of their own accord, while the successful cases 
frequently never gave the chance of a later examination. 

During the five years, 1889 to 1893, there have been 
1,519 cases of cataract extraction. The majority (1,091) 
have had iridectomy done at the time of the extraction. 
Some (257) were extracted without an iridectomy being 
done at all, and the remainder (161) were done after a 
preliminary iridectomy. 



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HO 



ON THE IMMEDIATE AND REMOTE 



Table I. 



Year. 


Total. 


Number 

with 

iridectomy. 


Number 

without 

iridectomy. 


Number 

after 

preliminary 

iridectomy. 


Number after 

previous 

iridectomy for 

disease. 


1889 

1890 

1891 

1892 

1893 


310 
280 
308 
293 
328 


247 
197 
177 
204 
266 


34 

47 
96 
56 
34 


28 
33 
33 
31 
23 


1 

3 
2 

2 
5 


— 


1519 


1091 


267 


148 


13 



Percentage of above Table. 



1889 




79'67 


10-96 


9'03 


0-32 


1890 


— 


70-35 


16-78 


11-78 


1-07 


1891 


— 


57-46 


31-16 


10-71 


0-64 


1892 


— ~ 


69-62 


19-11 


10-57 


0-68 


1893 


— 


81-09 


10-36 


7 01 


1-52 


— 


303 '88 


71-64 


17 -67 . 


9-82 


0'85 



There are one or two points which must be noted with 
regard to the operation that was performed. Those cases 
in which the lens was extracted without an iridectomy are 
to a certain extent picked cases, that is to say, they include 
but few where previous disease had existed, or where 
there was reason to believe that the eye was unhealthy. 
Those cases in Avhich iridectomy was done at the time of 
the extraction include a large number of eyes which were 
to all appearances healthy, except for the presence of the 
cataract, but there are also in this group a good many 
cases in which signs of previous disease were manifest. 

Those cases in which extraction was done after pre- 
liminary iridectomy include, a very large number where 
disease was known to have existed, and many other cases 
where the eye was permanently damaged before the 
operation for the removal of the cataract was undertaken. 



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RESULTS OF CATARACT EXTRACTION. 61 

The percentages of vision were taken from the total 
number of recorded cases (1,257) and not from the total 
number of cases operated upon ; this applies to some of 
the other items as well. 

The cases included in the first group (V. = 6/6 and J. 1 
to 6/18 and J. 6) are chiefly taken from the column of 
remote visions (see large table), but when the immediate 
vision indicates that the operation has been undoubtedly 
successful it has been included. Unless such a case has 
a vision of at least 6/24, it has been classed among the 
unrecorded cases, there being but little doubt that a 
patient who can see 6/24 within two weeks, or there- 
abouts, of an operation for extraction will in a short time 
be able to see 6/18, and very possibly still more. 

If a patient's immediate vision equals " hand-move- 
ment," or even less, and there is a condition present which 
makes one practically certain that it will never be better, 
1 have included it in the third column (hand-movement 
and less). The two intermediate columns include only 
those cases in which vision at a remote period has been 
recorded. If a case is noted to have hand-movement as 
an immediate result, while the remote vision is unrecorded, 
and it is stated also that lens matter is present which 
would account for the bad sight, such a case I have in- 
cluded in the list where there is no vision recorded. The 
percentage of vision resulting after the three chief varie- 
ties of operation brings under notice one or two in- 
teresting facts. See Table II. 

In the first column (V. = 6/ 6 J. 1 — 6/18 J. 6) we see 
that the operation without iridectomy gives the highest 
percentage (78*38) but as has been pointed out, the cases 
included in this list contain but few which show any 
marked sign of disease, and it is certain that this group 
has a higher percentage of cases favourable for operation 
than the other two. 

However, the second group of cases, in which the 
iridectomy was done at the time of the extraction, does 



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62 ON THE IMMEDIATE AND REMOTE 

not fall very far short of the preceding (76*28) in spite of 
the fact that we certainly have a good number of unfavour- 
able cases. 

The third group, in which preliminary iridectomy was 
done, does fall considerably below the other two (73*20)* 
but we have here a much higher percentage of unfavour- 
able cases. 

In the fourth column (V. = hand-movement and less) 
there is a rather marked difference. The highest percent- 
age is in the group of extractions after preliminary iridec- 
tomy (5*99), and for the reason above mentioned this is 
much what one would expect. But we find that in those 
cases in which no iridectomy was done the percentage very 
nearly equals it (5*53), while in those in which the iridec- 
tomy was done at the time of the extraction it is lowest 
of all (4*95). This I take it is distinctly in favour of the 
operation with iridectomy. 

In the second column of visions (V. = 6/24 — 6/60), 
the percentages are about equal. 

In the third column (V. = 5/60 to counting fingers) 

there is again a marked difference ; the group of cases in 

which no iridectomy was done contains only 2*47 per cent., 

ivhile the groups with iridectomy and after preliminary 

ridectomy contain 5*21 and 6*69 per cent, respectively. 

These figures go to prove an observation frequently 
made that cases of extraction without iridectomy when they 
do well give the best possible results, but should any com- 
plication occur they generally do much worse than those 
in which an iridectomy has been performed. If we now 
include as successful those cases which have vision of at 
least 6/60, as Knapp and other surgeons have done, we 
find the following result : — 

(1.) Extractions without iridectomy 91*97 per cent. 
(2.) Extractions with iridectomy 

done at the same time .... 89*81 „ 
(3.) Extractions after preliminary 

iridectomy . , . .... ♦ , . 87*29 ? , 



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RESULTS OF CATARACT EXTRACTION. 



63 



but what we have said about the selection of cases must 
be borne in mind. 

Table II. 
Results of Extractions with Iridectomy. 



Year. 


Number 

of 

cases. 


Y. = 6/6 
J.l 

to 6/18 J. 6. 


Y. = 6/24 
to 6/60, 


Y. = 5/60 

to counting 

fingers. 


Y. = hand- 
movement 
and less. 


No vision 
recorded. 


1889. . 
1890. . 
1891.. 
1892. . 
1893. . 


247 
197 
177 
204 
266 


135 
118 
115 
134 

178 


33 
16 

20 
19 
35 


10 
9 
6 
9 

13 


11 
11 

4 
12 

5 


58 
43 
32 
30 
35 


— 


1091 


680 


123 


47 


43 


198 



Results of Extractions with Preliminary Iridectomy. 



1889.. 


28 


15 


7 


_ 


2 


4 


1890. . 


33 


22 


2 


2 


1 


6 


1891.. 


33 


20 


1 


4 


1 


7 


1892. . 


31 


20 


4 


3 


1 


3 


1893,. 


23 


14 


3 


— 


2 


4 


— 


148 


91 


17 


9 


7 


24 



Results of Extractions -without Iridectomy. 



1889. . 


34 


17 


6 


2 


1 


8 


1890. . 


47 


33 


6 


1 


1 


6 


1891.. 


96 


74 


10 


— 


3 


9 


1892. . 


56 


37 


3 


1 


4 


11 


1893. . 


34 


26 


4 


— 


3 


1 


— 


267 


187 


29 


4 


12 


35 



Results of Extractions after Previous Iridectomy for Disease. 



1889- 
1893 



13 



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(54 



ON THE IMMEDIATE AND REMOTE 



Table II (continued). 
Results per cent, of Extractions with Iridectomy. 



Year. 


Number 

of 

recorded 

cases. 


Y. = from 
6/6 J. 1 to 
6/18 J. 6. 


Y. = from 

6/24 

to 6/60. 


Y. =• from 
5/60 to 
counting 
fingers. 


y. = hand- 
movement 
and less. 


Average 

number of 

recorded 

cases. 


1889. . 
1890. . 
1891.. 
1892.. 
1893. . 


189 
154 
145 
174 
231 


71*42 
76-62 
79-31 
77-01 
77-05 


17"46 
10-38 
13-79 
10-91 
15-15 


5-29 
5-84 
4-13 
5-17 
5-62 


5-82 
7-14 
2-75 
6-89 
2-16 


-"■■ 


— 


893 


76 '28 


13-53 


5-21 


4-95 


178-6 



Results per 


cent, of Extractions with Preliminary Iridectomy. 


1889. . 
1890. . 
1891.. 
1892. . 
1893.. 


24 
27 
26 
28 
19 


62-50 
81 -48 
76-92 
71-42 
73-68 


29-16 
7-40 
3-84 

14-28 

15-78 


7-40 
15-38 
10-71 


8*33 
3-70 
3-84 
3-57 
10-52 


— 


— 


124 


73*20 


14-09 


6*69 


5-99 


24-8 



Results per cent, of Extractions without Iridectomy. 



1889. . 


26 


65*38 


23-07 


7-69 


3-84 





1890. . 


41 


80-49 


14 63 


2-43 


2-43 


— 


1891.. 


87 


85-05 


11-49 


— 


3-44 


— 


1892. . 


45 


82-22 


6-66 


2^22 


8-88 


— 


1893. . 


33 


78-78 


12-12 


— 


9-09 


— 


— 


232 


78 k 38 


13-59 


2-47 


5-53 


46-4 



In Table III we see the number of males and females, 
and the number of right and left eyes that were operated 
upon. 

There were 117 more females than males, but when 
one takes into consideration the fact that there is a larger 
proportion of women in the population, the difference in 
the percentage would not really be very great. 

There were rather more right eyes operated upon than 



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RESULTS OF CATARACT EXTRACTION. 



65 



left, possibly clue to the fact that most right-handed 
surgeons when they have the choice of operating upon 
two eyes equally affected usually prefer to do the right. 

Table III. 

Table showing the Sex of the Patients and the operations on the 
Bight and Left Eyes. 



Year. 


Number 
of cases. 


Male. 


Female. 


Right. 


Left. 


1889 

1890 


309 

282 
307 
293 
328 


146 
131 
130 
133 
161 


163 
151 

177 
160 
167 


154 
158 
151 
147 
177 


155 
124 


1891 , 


156 


1892 


146 


1893 


151 






— 


1519 


701 


818 


787 


732 



Percentage. 



1889—1893. 



Average 
303-8 



46'14 



53-86 



51-81 



48 -3 9 



Table IV shows the number of cases in which a pro- 
lapse of the iris occurred after extraction with and with- 
out iridectomy. 

Here, as we should expect, the latter operation will not 
bear comparison with the former ; in the one case we have 
13-86 per cent., while in the other only 0*87 per cent. 

It has been suggested that the cause of so many pro- 
lapses after extraction without iridectomy is the fact that 
the operation at Moorfields is not done with the patient in 
bed, and that the movements made after the extraction 
cause the prolapse. This view, however, cannot be sub- 
stantiated by fact. I have frequently examined a case 
within an hour or more of the operation when the patient 
is back in bed, and (provided there has been a good con- 
junctival flap) found the anterior chamber re-formed, the 
wound closed, and the pupil circular. Yet a few hours 



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66 



ON THE IMMEDIATE AND REMOTE 



later the iris has become prolapsed and the anterior 
chamber obliterated. This is probably brought about by 
the patient squeezing the lids or making some slight 
movement of the facial muscles sufficient to cause a little 
extra pressure on the globe ; the result is that the wound 
is opened, the aqueous escapes and carries the iris with it. 
A second iridectomy has then to be done under very 
unfavourable conditions and often with the aid of a 
general ansesthetic. This is the usual way in which pro- 
lapse occurs, but there is still another way, and I now 
refer to those cases in which the iris remains in position 
for several clays; the pupil is seen to become more and 
more pushed up to the wound, and finally a prolapse takes 
place. Many of those cases are due to soft lens matter 
having been left behind after the bulk of the lens has been 
removed; this is out of reach, as it is underneath the iris, 
and as time goes on it swells and causes a prolapse. 

Table IY. 
Showing cases of Prolapse of Iris after Cataract Extraction. 



Year. 


Number of 
cases of 
prolapse after 
extraction 
without iri- 
dectomy. 


Number of 

cases of 

prolapse after 

extraction 

with 
iridectomy 


Percentage of 

prolapses after 

extraction 

without 
iridectomy. 


Percentage of 

prolapses after 

extraction 

with 
iridectomy. 


1889 

1890 

1893 


2 

8 

11 

13 

4 


1 

4 
2 
2 


5-88 
17-02 
11-45 
23 21 
11-76 


0-40 
2-25 


1892 

1893 


0-98 
0-75 


— 


average 
38 7*60 


average 
9 1-80 


13-86 


0-87 



Among the complications that may occur at the 
time of the extraction, loss of vitreous is one of the 
most important. It usually happens in eyes in which 



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RESULTS OF CATARACT EXTRACTION. 



67 



there is some pre-existing disease; the vitreous is more 
fluid than natural, and the hyaloid membrane is either 
extremely thin or has perhaps given way (see Table V). 
The percentage is lowest in those cases operated upon 
without iridectomy (2*99). From this, however, we can 
by no means conclude that the chance of losing vitreous 
is less than after an iridectomy has been done, rather the 
reverse ; the difficulty that there sometimes is in removing 
the lens through an intact pupil is certainly greater than 
when a coloboma exists ; we must rather put it down to 
the fact that in this group of cases we are dealing with a 
greater percentage of eyes which are free from any serious 
disease. 

Table V. 
Cases in which Vitreous was lost at Extraction and their Results • 





tk 


a 

o 


t^ 


o 

r-l 


o 

CO 


| 


T3 

3 


pi 

o 






S 


o 


o3 

3 . 


hsco 


CO 


o 
o 




'p 




Year. 


-4^> 

o 
•■a 


o 






1 




5 
o 


^o 
o 


PI 

a 






r3 


^3 


11 s- 


II 


II g> 


^ go 

w 


o 




1889 .... 


9 




2 


3 


1 


1 


1 


5 




1890 .... 


7 


3 


2 


4 


1 




3 


4 


. 


1891 .... 


7 


2 


4 


6 


4 


1 


1 


1 


_ 


1892 .... 


11 


3 


3 


7 


3 




1 


5 


1 


1893 .... 


7 


— 


5 


3 


3 


2 


1 


2 


1 


— 


41 


8 


16 


23 


12 


4 


7 


17 


2 




Percentage of above Table for 


the Fit 


>e Year^. 




Total. 




















4-27 


3-75 


2-99 


10*81 


47 -91 


25 -00 


8-33 


14-58 


26*15 


4-16 



In the operation with iridectomy at the time of 
extraction the percentage of cases in which vitreous is 
lost is not very much higher (3*75) ; but after preliminary 
VOL. xiv. ir 



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ON THE IMMEDIATE AND REMOTE 



iridectomy the percentage is much greater (10*81). We 
must again remember that in this group we have a very 
large number of unhealthy eyes. The percentage of all 
cases which fall into the group usually termed " successful " 
(V. = 6/6 - 6/60) is 72-91. 

The percentage of cases whose vision = hand-move- 
ment and less is certainly large (14*58), and 4*16 per cent, 
finally come to excision. 

Table VI gives the number of cases in which the 
extraction was followed by an increase in the tension of 
the globe. 

The lowest percentage belongs to the group in which 
extraction was done with iridectomy at the same time 
(0*42). 

The highest percentage is seen in the cases of extrac- 
tion without iridectomy (1*17). 

After preliminary iridectomy the percentage is 0*71. 
The causes which lead to this condition are fully discussed 
in a paper by Mr. Treacher Collins in the Ophthalmo- 
logical Society's Transactions, vol. x, and still more 
recently in the lectures delivered by him at the Royal 
College of Surgeons in 1894. 



Table VI. 
Glaucoma following 'Extraction. 



Year. 


G 1 au com a follow- 
ing extraction 
with iridectomy. 


Grlaucoma follow- 
ing extraction 
without 
iridectomy. 


Glaucoma follow- 
ing extraction 
with preliminary 
iridectomy. 


1889 , .. . 


1 
1 

1 

2 


2 


1 


1890 




1891 

1893 


— 


1893 ... 


— 


— 


5 


2 


1 



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RESULTS OF CATARACT EXTRACTION. 



69 



Table VI {continued). 



Year. 


Percentage of 
glaucoma follow- 
ing extraction 
with, iridectomy. 


Percentage 

without 
iridectomy. 


Percentage after 
preliminary 
iridectomy. 


1889 


0-40 
50 

0-49 
0*74- 


5'88 


3*57 


1890 




1891 




1892 




1893 








— 


0-42 


1-17 


0-71 



Table VII shows the number of cases in which some 
unfavourable condition existed in the patient's general 
condition and in the eye. 

In* the former group there were 244 or 16-06 per cent., 
and of these 7, or 0*46 percent., suffered from albuminuria, 
and 30, or 1*97 per cent., from diabetes. 



Table 



Table VII. 

the Number of Cases in which unfavourable condi- 
tions existed in the Bye or in the Patient. 



Percentage. 



Year. 


Uufavourable conditions in 


Unfavourable conditions in 




eye. 


patient. 


1889 


62 


41 


1890 .... , .. 


66 


38 


1891 


59 


49 


1892 


73 


47 


1893 


68 


69 




32S 


24^h 



1889-1893 



21-59 



16-06 



F 2 



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70 



ON THE IMMEDIATE AND REMOTE 



Table YII (continued). 

Results of Qatar act Extraction in Patients suffering from 
A Ibuminuria. 



Year. 


Number 

of 

recorded 

cases. 


Y. = 6/6 

J. 1 to 

6/18 J. 6. 


Y. = 6/24 
- 6/60. 


Y. = 5/60 

to 
counting 
fingers. 


Y. = 

hand- 
movement. 


Y. not 

recorded. 


1889.. 
1890. . 
1891.. 
1892. . 
1893. . 


1 

3 
1 

2 


1 


1 
1 


1 

1 


— 


1 
1 




7 


1 


2 


2 


~~ 


2 



Percentage. 



0-46 20-00 40-00 



40-00 



28-5? 



Result of Cataract Extraction in Patients suffering from Diahetes. 



1889. . 


2 


i 


1 




_ 





1890. . 


i 


2 


1 


1 


— 


3 


1891. . 


6 


2 


1 


— 


— 


3 


1892. . 


6 


3 


1 


1 


— 


1 


1893. . 


9 


2 
10 


4 


1 


— 


2 




30 


8 


3 


— 


9 



Percentage. 



•97 



47-61 



38 -08 14 -28 



30-00 



It will be seen that the result of these cases, though 
by no means bad, is distinctly less favourable than when 
the operation is performed upon people healthy in other 
respects. This is, of course, exactly what one would 
expect. 

The number of cases operated upon while the patients 



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RESULTS OF CATARACT EXTRACTION. 



71 



were suffering from albuminuria is too small to allow on9 
to draw any trustworthy conclusions. 

There were 328 cases, or 21*59 per cent., in which 
some unfavourable condition existed in the eye of the 
patient before the operation was performed. 

Table VIII gives the total number of cases that were 
operated upon during the different ages. 

The number of cataracts extracted from patients 
between the ages of 60 and 70 equalled nearly half of the 
total number, 41 '34 per cent. 

Table VIII. 
Table showing the age of the Patients operated upon. 



Tear. 


90 and 
upwards. 


80-90. 


70—80. 


60—70. 


50—60. 


Below 
50. 


1889. . 
1890. . 
1891. . 
1892. . 
1893. . 


1 
1 


8 
6 
5 

7 
8 


67 
66 

87 
85 
79 


138 
114 
132 
119 
125 


56 

59 
55 
52 
73 


40 
36 
28 
30 
42 


— 


2 


34 


384 


628 


295 


176 



Percentage of Ages. 



1889— 
1893 



0-13 



2-23 



25-27 



41-34 



19-42 



11-53 



The two oldest patients operated upon were both 90 
years of age. 

Table IX shows the number of cases in which 
secondary complications followed extraction, but exclud- 
ing suppuration, glaucoma, and sympathetic ophthalmia. 

Previous disease in the eye greatly affects the result 
of operations. 



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72 



ON THE IMMEDIATE AND REMOTE 



Table IX. 

Table showing the number of Gases where other secondary com- 
plications followed Extraction besides those mentioned in the 
preceding Tables. 



Year. 


Secondary complications 
after extraction. 


1889 


106 


1890 


81 


1891 


96 


1892 


92 


1893 


113 






— 


488 



Percentage. 



1889-1893.... 



32-11 



Table X. 
Results of Extraction in Eyes which have had Iritis or Keratitis. 













-1-2 














-p 


PI 








co 
1) 
co 

33 

o 


o 

i-l 


© 
co" 

1 


9 

o 

o 


CD 

a 

CD 
O 


CD 
^5 




Year. 


o 


H"5 CO 


CM 


o ° 

8g> 


n3 aJ 

r-j CO 


O 
o 
CD 


CO 

PS 




CD 


<& ~rs 


CO 


ic qn 






o 




r£ 


GO 
II ^1 

CO 


II 


II ^ 


"l.S 


O 


'o 
M 




£ 


> 


l> 


t> 


\> 


l> 


W 


188* .. 


14 


2 


2 


2 




6 


2 


1890 .. 


12 


1 


3 


— 


3 


5 


— 


189L .. 


10 


6 


1 


1 


— 


1 


1 


1892 .. 


17 


6 


3 


4 


1 


3 


— 


1893 .. 


13 


2 


3 


2 
9 


2 


3 


1 


— 


66 


17 


12 


6 


18 


4 



Percentage of above Table for the Five Years. 



1889 — 
1893 



4-34 



35-41 



2.5-00 



18-75 



12-50 



27-27 



8-33 



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RESULTS OF CATARACT EXTRACTION. 



73 



Table X shows the number of cases that were operated 
upon after having had keratitis or iritis. 

I 'endeavoured to separate the two, but this I found 
almost impossible, for most of the cases which had corneal 
nebulae also had posterior synechias, and thus one could 
not put them in one or other table separately. There 
were 66 cases giving a percentage of 4*34. 

The percentage of cases whose vision ranged from 
6/6 to 6/60 was 60-41. 

The percentage of those which only obtained hand- 
movement or less is high (12*50). 

The number of eyes which were excised reaches the 
very high percentage of 8*33. In this group are included 
some cases in which primary suppuration occurred after 
the extraction. 

Table XI gives the number of cases of black and 
darkly coloured cataracts that were .extracted. 



Table XI. 
Results of Extraction of Black and Darkly coloured Cataracts. 



Year. 


Total. 


o 

rH 

1-2 CD 

co _; 
1! C 

CD 


© 

CD~ 
1 

co" 

II 


o 
o 

S p 

o ^ 

gg, 

ID cfl 
II g> 


5 

> 
o 

a 
^ i 

'I g 
> 

3 

2 

5 


*c» 
"P 
*w 
O 

V 

O 

o 
9 

o 
fen 

3 
1 
1 

1 

6 


-T5 

co 

.2 a 


1S89 .. 

1890 .. 

1891 .. 

1892 ., 

1893 .. 


16 

5 
7 
3 
2 

33 


.6 

.5 
1 

12 


3 

1 
1 

5 


2 

1 
1 

4 


1 


— 


1 



1889— 
1893 



Percentage of above Table for the Fire Tear 



2-17 



U 'U 



18-51 14-81 



18-51 



18 '18 



3-71 



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74 



ON THE IMMEDIATE AND REMOTE 



Table XI (continued). 
Conditions of IS yes with Black Cataracts. 



Number. 


Myopic. 


Normal. 


Not recorded. 


Alb. retinitis. 


33 


17 


11 


4 


1 



Percentage. 



51 -51 



33-33 



12-12 



3-03 



They are commonly found in myopic eyes ; of these 
there were 17, or 51*51 per cent. The percentage of so- 
called successful cases (V. — 6/6 to 6/60) was 62*95. The 
percentage of cases in which there was only hand-move- 
ment is very high, 18*51, and 3*03 per cent, were excised. 

These figures uphold a common impression that the 
prognosis in cases of black cataract is somewhat unfavour- 
able. A glance at the table shows that a large number of 
these eyes are really diseased before the operation is 
undertaken. 

Table XII gives the number of cases in which suppura- 
tion occurred after the three chief operations practised for 
the extraction of cataract. 



Table XII. 
Suppurations after Extractions. 



Year. 


After extraction 

with 

iridectomy. 


After extraction 

without 

iridectomy. 


After extraction 

with preliminary 

iridectomy. 


1889 

1890 ,. 

1891 

1892 

1893..., .. 


8 
4 
2 
3 
2 


1 

1 
2 
1 


1 
1 


— 


19 


5 


2 



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RESULTS OF CATARACT EXTRACTION". 



75 



Table XII {continued). 



Year. 


Percentage after 
iridectomy. 


Percentage without 
iridectomy. 


Percentage after 
preliminary 
iridectomy. 


1889 

1890 

1891 

1892 

1893 


3-23 
2-03 
1-12 
1-47 
0-75 


2-94 
2-12 
2-08 
1-78 


3 57 
4-34 


Average . . 


1-72 


1-78 


1*58 



The highest percentage occurs in the cases in which 
extraction was done without iridectomy (1*78), and the 
lowest in the cases extracted after preliminary iridectomy 
(1*58) ; those done with iridectomy at the time of the ex- 
traction occupy an intermediate position (1 # 72). 

It is very significant that the cases in which the simple 
operation was done provide the highest percentage of 
suppurations. This group, which contains the largest 
proportion of the healthiest eyes, certainly ought to give 
the least number of suppurations, supposing that one 
operation were not beset with more danger than another ; 
but the frequency of prolapse occurring after the opera- 
tion without iridectomy must be considered a powerful 
factor in this process. An analysis of these cases is given 
in Table XV, and this will be referred to later on. 

Sympathetic ophthalmia following extraction of catar- 
act is, fortunately, a somewhat rare condition. Table 
XIII. 

The two operations with iridectomy give almost 
identical percentages, viz., 0*60 after preliminary iridec- 
tomy, and 0*61 after the other operation. 

There are no cases included in the list of extractions 
without iridectomy; but cases operated upon in this 
manner are certainly not exempt irom this complication. 



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ON THE IMMEDIATE AND REMOTE 



Table XIII. 
Sympathetic Ophthalmia following Extraction, 



Year, 


After extraction 

"with 

iridectomy. 


After extraction - 
without 
iridectomy. 


After extraction 

with preliminary 

iridectomy. 


1889 

1890 

1891 

1892 

1893 


1 
1 
1 
1 
3 


— 


1 


— 


7 


— 


1 




Year. 


Percentage after 

extraction 
with iridectomy. 


Percentage after 

extraction 

without iridectomy. 


Percentage after 
extraction with pre- 
liminary iridectomy. 


18S9 

1890 

1891 

1892 

1893 


0-40 
0-50 
0-56 
0-49 
1 11 


— 


3-03 


— 


0-61 


— 


0-60 



In Table XIV is given a classification of the cases 
according to the months in which they were operated 
upon, and for convenience of description the totals of the 
five years are discussed instead of taking each year 
separately. 

There were more operations done in the months of 
October (176) than in any other; and then follow the 
months of May, June, July, and November in this order. 

August contains the fewest number of operations (65). 

This table was got out for the purpose of ascertaining 
whether one month seemed more favourable to the de- 
velopment of iritis or suppuration after extraction than 
another. 

Of the total number in which this occurred we find 



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RESULTS OF CATARACT EXTRACTION. 



77 



that July has by far the highest percentage, 7*58. This 
at first sight is hardly what one would expect, for pre- 
sumably during the summer these elderly people would be 
suffering less from bronchitis and colds than they would 
be during the winter, and altogether their general health 
would be better. This is no doubt the case ; one must 
recollect, however, that there are many patients who 
would not venture on a journey from their country homes 
during the winter, but who make up their minds to do so 
when there is a prospect of fine weather; the result is 
that during the summer months a greater percentage of 
persons with low vitality are operated upon than at other 
times, and this in some measure accounts for the enormous 
increase in the development of iritis during July. 

Table X1Y. 
Number of Cases operated upon during the different months, and 
the number of Cases in which Suppuration or severe Iritis 
occurred during these months, together with, Fer cent ages. 



Months. 


Number of 

cases 

operated upon. 


Number of cases 
of severe iritis 
or suppuration. 


Percentage of 
these cases. 


January 

February 

March/, 


104 
122 

109 
129 
154 
148 
145 
65 
115 
176 
144 
108 


3 
6 
5 

5 

7 

4 

11 

3 

6 

2 
4 


2-88 
4-91 
4-58 
3-87 
4-54 
2-70 
7-58 

2-60 
3-40 
139 
3-70 


May 


June 


August 

September 

October 

November 

December 


— 


1519 


56 


— 



One reason for the greatly diminished number of cases 
of cataract extraction during August is the fact that many 
of the wards of the hospital are at that time closed for 



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78 



ON THE IMMEDIATE AND REMOTE 



cleaning purposes, and operations of this kind, about 
which there is no urgency, are, as far as possible, post- 
poned for a few weeks. 

The percentage of cases in which severe iritis de- 
veloped during October is by no means great, and during 
November it falls to its lowest point, viz., 1*39. 

Table XV gives the number of cases in which a 
secondary iridectomy for prolapse occurred after extrac- 
tion with and without iridectomy, and the results obtained. 
This is at once seen to be a serious complication to any 
operation. 

Of the 38 cases of prolapse of the iris after extraction 
without iridectomy, 83*78 per cent, obtained vision between 
6/6 and 6/60. 5*41 per cent, were not benefitted by the 
removal of the cataract, and the percentage of excisions 
reached the very high total of 8*10. Now, considering 
that these are mostly picked cases, the results of the 
operation cannot be considered as favourable. 



Table XV. 

Cases in wliicli Prolapse of the Iris occurred after Extraction, 
and their results. 











-i 














d 


fl 










en 


o 


CD 


3 

8 i 


© • 








CO 


i-l 


CD 










O 




1 


S b! 


B^ 


t5 






<4-i 


^ . 


^ 


^ 




T3 








CD l ~3 


<M 


CD ^ 


S 3 


*H 












-*- bJD 


c3 a 


O 


<3 







CO 00 
II 5- 


CD 
II 


II '" 


7 1 


© 

o 


.2 

H 




K 


t> 


t> 


t> 


t> 


£ 


S 


With iridectomy. . . 


9 


4 


1 


■ 


1 


3 




Without iridectomy 


38 


27 


4 


1 


2 


1 


3 



Percentage. 



With iridectomy . . . 
Without iridectomy 



0-87 
13 -86 



66-66 

72-97 



16-66 
10*81 



2-70 



16-66 
5-41 



33 -33 

2-63 



8-10 



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RESULTS OF CATARACT EXTRACTION. 



79 



There were only nine cases in which secondary iridec- 
tomy was done for prolapse after the operation with 
iridectomy. 

It is rarely necessary to extract a cataract while the 
patient is under the influence of a general anassthetic, 
and practically the only reason for giving it is to ensure 
an unsteady person keeping still. 99*68 per cent, of the 
cases were extracted under the local anaesthetic cocaine. 

Table XVI. 
Anaesthetics used at the Extraction. 



Tear. 


Cocaine 


Ether or chloroform. 


1889 
1890 
1891 
1892 
1893 


307 
280 
307 
293 
327 


2 
2 

1 




1514 


5 



Percentage. 



1889 -1893 



99-68 



0-32 



The secondary operations form an important item 
when considering the results of extractions. 

Dming the five years there were 404 operations per- 
formed for capsular opacities, and there were 108 other 
secondary operations, besides 29 excisions, making a total 
of 541, and when expressed in percentages it amounts to 
26*79 of secondary operations on the capsule, 7*04 of 
other secondary operations, and 1*90 of excisions. 

It is a well-known fact, and this can be seen by 
reference to the detailed description of cases, that after 
simple needling of thickened capsule the vision is 
materially improved s and, with few exceptions, normal 
acuteness of sight is obtained, provided that the eye is 



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ON THE IMMEDIATE AND REMOTE 



Table XVII. 
Secondary Operations. 



Year. 


Secondary 

operations on 

capsule. 


Other secondary 
operations. 


Excisions or 
eviscerations. 


1889 
1890 
1891 
1892 
1893 


71 
83 
93 
93 
64 


15 
13 

24 
25 
31 


11 

6 
3 

4 
5 




404 


108 


29 



Year. 


Percentage of 

secondary 

operations on 

capsule. 


Percentage 

of other secondary 

operations. 


Percentage of 

excisions 

or eviscerations. 


1889 
1890 
1891 
1892 
1893 


22 90 
29*64 
30*19 
31 -74 
19-51 


4-83 
4-64 
7-79 
8-53 
9-45 


3-54 
2-14 
0-97 
1-36 
1-52 




26-79 


7-04 


1-90 



healthy, and that no secondary complications supervene. 
I have, therefore, only tabulated the causes which lead 
to failure after these operations. Table XVIII. A certain 
number remain unimproved after needling, for the simple 
reason that the flap of capsule that is cut through, falls 
back into its original position, and obstructs vision as 
before. As a rule, a second needling is successful. 

What I chiefly want to bring under notice are the 
secondary inflammatory and degenerative conditions which 
unfortunately occur after needling of capsule, and which 
permanently diminish or even destroy the sight. 

These conditions are set forth in Table XVIII. 



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RESULTS OF CATARACT EXTRACTION. 



81 



Table XYIII. 

Complications occurring after Secondary Operations, but excluding 
Secondary Iridectomy for Prolapse. 



Year. 


No. of cases. 


Suppuration. 


Glaucoma. 


Other 

secondary 

complications. 


1889 
1890 
1891 
1892 
1893 


6 

9 

11 

11 

8 


1 
3 
1 


3 
3 

2 

2 


2 
3 
10 
9 
6 




45 


5 


10 


30 



Percentage. 



1889 




1-17 


3'52 


2-32 


1890 


— 


3 -(9 


3 09 


3-12 


189 L 


— 


85 


— 


8 54 


1892 


— 


— 


1 75 


7 62 


1893 


— 


— 


2-06 


6-31 




— 


1-02 


2-08 


5 58 



The two most formidable dangers are glaucoma 
(2*08 per cent.), and suppuration (1*02 per cent) ; besides 
these we get a number of cases in which slow inflamma- 
tory changes are set up in the eye, which ultimately 
diminish or even permanently destroy the sight (5*58 per 
cent.). 

First of all with regard to increased tension occurring 
after needling. The explanation of this condition is by 
no means easy. It is more often seen in those cases in 
which capsule is caught in the wound, though if there be 
tension before the secondary operation is undertaken, a 
free division of the capsule sometimes permanently relieves 
the glaucomatous condition. An explanation of this is 
given by Mr. Treacher Collins in his lectures at the Royal 
College of Surgeons, 1894. 

The second complication is suppuration. 



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82 ON THE IMMEDIATE AND REMOTE 

It is certainly a remarkable thing to find that this 
occurs in 1*02 per cent, of the cases needled, this being 
very nearly as high as what occurs after the far more 
serious operation of extraction. 

Now it is obvious that there must be some source of 
infection either from without or within. 

The actual state of things is this. A minute wound is 
made in the cornea with a needle, and the capsule is 
punctured. In most cases the point of the needle at 
least enters the vitreous, the thickened capsule is then 
cut or torn by its sharp cutting edge. Now we have a 
direct communication between the exterior and the 
vitreous chamber. In some cases I have seen a tag of 
capsule, or even vitreous, follow the needle, when it is 
withdrawn, right up to the corneal puncture, and even 
when this has not been noticed, I have frequently seen a 
tag caught in the wound and projecting from it within 
a day or so, and on careful examination one can often 
see it running across the anterior chamber back to 
the deeper parts of the eye. Now this is a very ready 
means by which the interior of the eye may become 
infected, and it is of the utmost importance to recognise 
it early, so that the tag may be removed ; in most 
instances it can be drawn out and cut off, and then if 
the puncture be touched with the galvano- cautery it is 
effectually sealed, and the danger is over. But, unfortu- 
nately, infection may have already taken place. One is 
sometimes able to see that the tag is the source of 
infection, and that purulent infiltration is starting from it. 

There is still another danger in the operation of 
needling. I refer to the physical violence that the iris 
and ciliary body suffer, when a tough membrane is being 
divided. Of course the danger is much lessened by using 
a needle with a very sharp cutting edge, but no matter 
how sharp the needle may be, it is impossible to avoid 
tearing the capsule in some cases instead of cutting it. 
This is seen in its extreme degree, when there happen to 



1 



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RESULTS OF CATARACT EXTRACTION. 83 

be posterior synechise present, and all operators must have 
observed haemorrhage occur at times from the iris or 
ciliary body, when a particularly tougli membrane which 
is adherent to the iris is being divided. All eyes will 
not stand this without showing some signs of resentment, 
and it is frequently these which give the bad results. 

In very briefly reviewing the results of the three chief 
operations for extraction, there are one or two points that 
I want to call especial attention to, and also I wish, as far 
as possible, to draw some practical conclusions as to the 
sort of operation that in equally expert hands is likely to 
give the greatest percentage of good results, and the 
least percentage of failures. 

There is a complication that almost entirely belongs to 
one group of cases, and that is secondary prolapse of the 
iris after extraction without iridectomy. We may almost 
disregard it in the other groups, for it occurs in less than 
1 per cent. 

Now it is an obvious fact, and one that is abundantly 
proved by the preceding tables, that prolapse of the iris 
after an extraction is a very serious thing. Most of these 
cases occur within the first 12 hours, and the result is 
that an operation has to be undertaken as soon as 
possible. 

If there is one thing more than another that is 
essential for success, it is keeping the patient absolutely 
quiet during the first few days after the extraction. Instead, 
however, of this, the patient has to submit to another 
painful operation, or else be put under a general anes- 
thetic, with all its evil accompaniments. The mental 
and physical conditions under these circumstances are 
very far removed from the ideal tranquil condition that is 
so much to be desired. The after vomiting may possibly 
lead to a loss of vitreous, and I have known intraocular 
haemorrhage to occur. 

And now to return for a moment to the condition of 
the eye when a prolapse takes place. 

VOL. XIV. G 



Hosted by G00gle 



84 ON THE IMMEDIATE AND REMOTE 

The wound is forced open, and the iris is pushed 
between the flaps. The result of this is : — 

First of all the edges of the wound are kept apart, and 
therefore no healing can take place. 

Secondly, there is a direct communication from the 
conjunctival sac into the interior of the globe, and a 
road is open for the inlet of any septic organisms that 
may be present. 

Thirdly, the iris is not only prolapsed, but is also 
nipped in the wound, and it is under much the same sort 
of physical conditions as are met with in the case of a 
strangulated hernia, and even supposing gangrene does 
not occur, yet the delicate circulation of the iris is con- 
siderably interfered with, the veins get engorged, the iris 
swollen and oedematous, and, if left long enough, covered 
with plastic exudation. An iridectomy must at once be 
done, but it is impossible to conceive of more unfavour- 
able conditions under which to perform the operation. 
After the prolapse has been removed, the lips of the 
wound refuse to fall into place again, and it is often 
most difficult to get the cut edges of the coloboma into 
position within the eye ; this is readily proved by the 
number of cases in which the iris is subsequently noted 
as being still entangled. In some cases a small prolapse 
again takes place. The result is that the eye is in a very 
dangerous condition, partly owing to the fact that iritis may 
be easily set up and possibly even sympathetic ophthalmia 
may occur. And supposing these serious conditions fail 
to manifest themselves, we almost necessarily have a 
cyst oid cicatrix which is anything but desirable. I do 
not, of course, mean to suggest that every case of prolapse 
is bound to be followed by these serious consequences, 
for there are many in which excellent vision is obtained, 
but the risk that is run is at once seen by reference to 
Table XV. 

These figures are sufficient to show what an extremely 
serious occurrence a secondary prolapse of the iris is. 



Hosted by 



Google 



RESULTS OF CATARACT EXTRACTION. 85 

Should a severe iritis be set up, it is obvious that the 
chances of getting a blocked jDupil would be far greater 
in a case in which no coloboma existed. 

No such marked difference can be drawn between the 
two groups where iridectomy is done. The fact that 
the cases in which preliminary iridectomy is performed 
contain such a much larger percentage of eyes in which 
previous disease has existed, prevents us putting the two 
side by side and comparing them. But, taking all things 
into consideration, it appears that there is but little to 
choose between the two. 

In conclusion, I have to express my gratitude to the 
members of the surgical staff of the fioyal London 
Ophthalmic Hospital for allowing me to use the notes of 
their cases, and I am especially indebted to Mr. Nettleship 
for several suggestions, and for kindly placing at my 
disposal some tabulated results of his own cases, and 
thereby saving me much time and labour. 

My best thanks are also due to Dr. H. V. McKenzie 
for his invaluable help in assisting me to arrange the 
tables, and in checking the results. 



r~ 3 



Hosted by GOOgle 



8 G 



ON THE IMMEDIATE AND REMOTE 



[1889 











'cS ^ 








p/Sjo 


tiye. 


Age. 


Sex. 










X* 









R. 



Condition 
of eye. 



Condition 
of patient. 



Operation. 



Complications 

at time 
of operation. 



2 
3 

4 

5 

6 

7 
8 

9 

10 

11 
12 



13 
14 

15 

16 

17 

18 



19 

20 



21 
2:' 



1 

41 


1 


56 


F. 


63 


1 




M. 


243 


2 


44 


M. 


412 


1 


66 


F. 


482 


2 


65 


M. 


48S 


1 


.18 


F. 


504 


2 


65 


F. 


515 


1 


57 


M. 


571 


1 


65 


M. 


623 


2 


60 


M. 


692 


2 


68 


M. 


732 


1 


77 


M. 


747 


2 


68 


M. 


821 


1 


76 


M. 


822 


1 


65 


M. 


858 


1 


66 


F. 


1356 


1 


71 


F. 


1416 


1 


51 


F. 


1498 


1 


60 


F. 


169L 


2 


67 


M. 


IP92 


1 


67 


M. 


1768 


1 


45 


F. 



GrOOcl. 



Results of 

old iritis 
Good 



Good 



Incomplete 
cataract 

Brown cata- 
ract 

Hypermature 
cataract 



Good 

)j 

Brown nu- 
cleus 
Good o . . . . 

5? 

JJ ' 

)) 

Corneal ne- 
bula 



Good 

Rheumatic . 
Cough 

Good 

Cough 

Good 

» 

j, ...... 

55 • 

Paralysis agi- 
tans, alco- 
holic 

Hemiplegic . 

Good 



Cough 
Good . 



Corneal section. 
Iridectomy, cap- 
sulotomy with 
cystotome 



Usual operation, 
but peripheral 
capsulotomy 

Usual operation . 



Peripheral cap- 
sulotomy 
Wound enlarged 

Peripheral cap- 
sulotomy 

Usual operation . 

Peripheral cap- 
sulotomy. 
Wound en- 
larged. Lens 
extracted with 
scoop andvectis 

Peripheral cap- 
sulotomy 



Usual operation 



Peripheral cap- 
sulotomy 

Usual operation 
Peripheral cap- 
sulotomy 
Usual operation . 



Some soit matter 
left 



None 

Soft matter left 

None .. 

Vitreous pre- 
sented 

Opaque matter 
left 

None 

Lens difficult to 

deliver 
Soft matter left 

None 

Bead of vitreous 
lost 

None 

,, ...... 

j? • • • • 

3> 

)) 

>> 

)) 

Tris transfixed 
Much bleeding 
in A.C. 



Hosted by GoOgle 



1889] 



RESULTS OF CATARACT EXTRACTION. 



87 





Secondary 
complications. 


Immediate 
result. 


Remote 
result. 


Secondary 
operations. 


Complica- 
tions after 
secondary 
operations. 


Result 
after 2nd 
operation. 


Remarks. 




None 


Fingers at 
2' 


1/60 J. 20 


Needling 


None 


b*/18 J. 1 


Subsequently, vitre- 
ous opacities and 
choroiditis reduced 




>> 

jj ........ 

,, ........ 


6/60 J. 10 
6/36 J. 8 


Hand- 
movement 
6/9 J. 1 


Iridotomy 


" 


6/60 J. 10 


vision much. 
R. did fairly well. 




J, ........ 

Purulent iritis 


6/36 J. 16 

Hand- 
movement 
6/60 J". 12 
J. 20 


6/12 J. 2 

Fingers at 

2' 
6/24 

J. 20 


Needling 
Needling 


None 
None 


6/12 J. 1 
6/18 J. 6 


L. did fairly well, but 
C. was nebulous. 

R. did well. 




Suppu 


ration 


•• 


Excision 










Capsule in- 
volved in 
wound 

x> T i?.ne 

Severe iritis. . . 

r 


J. 20 
6/12 J. 1 


Fingers at 
2' 


Needling 


" 


6/18 J. 2 


L. did well, but 
changes at macula 
destroyed vision. 

R. did well. 




Fingers at 
12" 


Fingers at 
12" 












J 


J. 6 


.. 








L. did well. 




/Suppu 

j 


ration 




Excision 


•• 


•• 


Primary suppura- 
tion. 




Severe iritis. . . 


6/60 J. 16 














None A 

Iritis. ( Pro- 
lapse of ai^gle 
of iris 

None I ...... . 

>) \. 


1/60 

6124s ' 

3/60 J. 16 


1/60 
3/60 

6/6 J. 1 


Needling 2 

Needling 
Iridectomy 
for pro- 
lapse 


None 
None 


6/60 J. 10 

6/24 
6/36 J. 1 


Still some opaque 

lens matter. 
Still some capsule. 

R. did well. 




" ] 


1/60 
1/60 


6/60 
6/18 J. 1 


Needling 


None 


6/9 J. 1 





Hosted by GOOgle 



ON THE IMMEDIATE AND REMOTE 



[1889-1890 



Htf 



Eye 



Sex. 



R. 



Condition 
of eye. 



Condition 
of patient. 



Operation. 



Complications 

at tune 
of operation. 



23 


1771 


2 


77 


M. 


L. 


24 


1772 


2 


58 


M. 


L. 


25 


1821 


2 


52 


M. 


L. 


2« 


1844 


2 


66 


F. 


R. 


27 


1855 


2 


53 


M. 


L. 


28 


1899 


1 


59 


P. 


L. 


29 


1940 


1 


60 


F. 


R. 


30 


1959 


2 


57 


M. 


L. 


3). 


2031 


1 




M. 


L. 


32 


2183 


1 


63 


P. 


R. 


33 


2253 


1 


55 


P. 


R. 


34 


2253 a 


2 


55 


P. 


R. 


35 


2255 


1 


58 


P. 


R. 


36 


2278 


1 


63 


P. 


L. 


37 


1016 


1 


70 


M. 


L. 



Good . 



Old iritis 

and P.S. 
Good 



Cold 



Good . 



Usual operation . None 



Lens tight . 



After preliminary 
iridectomy 

Usual operation . 



Incision enlarged, 
otherwise usual 
operation 

Usual operation . 



Soft matter left 



None 



Djff^ult to de- 



1 


198 


2 


63 


P. 


L. 


2 


15S 


1 


60 


M. 


R. 


3 


197 


1 


81 


P. 


L. 


4 


£14 


2 


67 


P. 


L. 


5 


398 


1 


60 


M. 


R. 


6 


399 


1 


56 


M. 


R. 



Good 



Black cata- 
ract 

Glaucoma- 
tous 

Old iritis . . 



Projection 

faulty 
Good 



Good 



Section upwards. 
With. iridec- 
tomy. Capsule 
opened with 
cystotome 

Usual operation, 
but incision had 
to be enlarged 

After iridectomy 
for glaucoma 

Usual operation . 



A little\ yitreous 
lost 



None . . J, 

Soft mat\ter left 



None . . { 



Hosted by GOOgle.' 



1889-1890] 



RESULTS OF CATARACT EXTRACTION. 



89 



Secondary 
complications. 



K. striata. Vi- 
treous opaci- 
ties 

None ....... 

>> 

>> 

)5 

,, ....... 

Iritis and P.S. 
None , 



Immediate 
result. 



J". 16 



J. 14 



6/60 J. 16 

1/60 

1/60 



6/36 J. 14 
6/36 J". 14 

6/60 J. 12 
6/36 

6/24 



6/60 J. 15 
6/60 J". 12 



Remote 
result. 



3/60 

6/12 J. 6 
6/24 J. 4 



6/12 J. 1 
6/18 J. 1 
4/60 



6/9 J. 1 
6/36 

6/12 J. 4 
6/12 J. 4 
6/12 J. 4 

6/24 
6/9 J". 1 
6/60 J. 15 



Secondary 
operations. 



Capsule 
extraction 



Needling 



Needling 
Needling 



Complica- 
tions after 
secondary 
operations. 



None 



Needle 

puncture 

cauterized. 



Result 
after 2nd 
operation. 



6/9 J. 



6/9 J. 1 



6/6 J. 1 
1/60 J. 20 



Remarks. 



R. almost suppu- 
rated after extrac- 
tion. 

R. extraction fol- 
lowed by iritis. 

R. lost after cata- 
ract ; extraction 
elsewhere. 

L. did well. 

R. did well. 



R. extraction and 
needling followed 
by much bleeding. 



R. did well. 
2253. 



No. 



Capsule still pre- 
sent. Vitreous opa- 
cities. 



Some iritis. . . . 



None 



Some iritis. 
None 



6/60 J". 10 



Hand- 
movement 



1/60 



6/60 



6/18 J". 6 



) J. 1 



Hand- 
Hi ovenient 



1/60 



6/6 J. 1 



, 6/36 J. 12 | 6/18 



Needling 



None 



I 



Needling 



Hand- 
movement 



6/9 J. 2 



Optic atrophy. 



R. blind from glau- 
coma. Some cap- 
sule left. 

R. did fairly well. 
No. 1940* (year 
1889). 



Hosted by GoOgle 



90 



ON THE IMMEDIATE AND REMOTE 



[1890-1891 



10 
n 

12 
13 
14 



15 

16 

17 
18 
19 

20 

21 

22 
23 
24 
25 



| _ I ^ 



W 



PS 



633 

744 
764 

783 

897 
996 

1136 

1433 

1490 

1512 

1527 
1572 
1573 

1583 

1611 

1697 
1707 
1719 
1848 



Eye. 



Age. 



Sex. 



Condition 
of eye. 



1 


64 


M. 


E. 


1 


73 


F. 


L. 


1 


80 


F. 


E. 


2 


59 


F. 


E. 


1 


51 


F. 


L. 


2 


57 


F. 


E. 


1 


69 


M. 


L. 


2 


54 


M. 


L. 


1 


59 


F. 


E. 


1 


75 


M. 


E. 


1 


56 


F. 


L. 


1 


58 


M. 


E. 


1 


45 


M. 


L. 


1 


66 


F. 


E. 


2 


63 


F. 


L. 


1 


70 


M. 


E. 


1 


70 


F. 


E. 


1 


66 


F. 


E. 


1 


65 


M. 


L. 



Small scar 

on cornea 
Good 



Myopic T + 



Cornea ne- 
bulous 
Grood 

,, . . . n . . 

Myopic 

Good 

>■> 

Morgagnian 

cataract 
Grood 



Condition 
of patient. 



Operation. 



Good...... 

Cough. .... 

Good 

5) 

jj ...... 

)) 

,, ...... 

Very feeble . 

Fairly good. 

G-ood 

Diabetic . . 

Good 

Eh. arthritis 
Good 



Usual operation . 
Incision enlarged 
Usual operation . 



Incision twice en- 
larged 
Usual operation . 



Incision had to 
be enlarged 



Complications 

at time 
of operation. 



None 

Lens difficult to 
deliver 

Some soft mat- 
ter left 

Bleeding from 
iris 

None 

J? • • • • 

» 

)> 

Soft matter left 
None 

Iris transfixed 
with knife 



Soft matter left 

Much bleeding 
None 



1 

2 


40 
221 
231 


1 
2 
1 


64 

70 
29 


F. 

M. 
M. 


L. 
E. 
E. 


Good 


Cough . . :. 
Good ...... 

Albuminuria 


Conjunctival flap. 
Iridectomy cap- 
sule opened 
with cystotome 

Usual operation . 


Small section . . 
None 




3 







Hosted by GOOgle 



1890-1891] 



RESULTS OF CATARACT EXTRACTION. 



91 













Complica- 








Secondary 


Immediate 


Remote 


Secondary 


tions after 


after 2nd 


Remarks. 




complications. 


result. 


result. 


operations. 


secondary 
operations. 


operation. 






None 


3/60 


6/60 


Needling 


.. 


.. 


Still much capsule. 




J) 


2/60 
6/60 J. 19 


6/36 J. 18 








Post, staphyloma 
and vitreous opaci- 
ties. 




5) 

)) 


6/18 

6/6 J. 1 

6/24 

6/12 J. 1 


6/6 J. 1 


•• 




•• 


L. did well. No. 
1899 (year 1889). 

L. did fairly. 




J) 


•• 


6/9 J. 1 


• • 


* • 




E-. operated else- 
where. Vitreous 
lost. Eye did 
badly. 




Some iritis. 


Hand- 


. , 


Excision 


. . 


, . 


Excised 3 months 




Sympathetic 


moyement 










later. 




ophthalmia 
















Very slowly 


6/24 


6/9 




.. 


• . 


illiterate. 




healing 
















Some iritis. . . . 


, , 


6/6 J 1 












None 


6/18 


6/18 J". 2 












Iritis , 


1/60 


5/60 






;: 


Vitreous opacities. 
Case did well. 




None 


3/60 


•• 


•• 




•'• 


R. did well. No. 
1498 (year 1889). 




Slight iritis. 
















None 


6/24 J. 10 
6/12 J. 4 


fi/24 J. 10 
6/9 












5) • • * 


3/60 


3/60 


Needling 




6/9 J. 1 







Hypha 



None 



2/60 



6 24 



6/36 J. 18 



L., No. 1016 (year 
1889). E. capsule. 
Central and peri- 
pheral choroiditis. 



Hosted by 



Google 



92 



ON THE IMMEDIATE AND REMOTE 



[1891 



d 
en 
e3 
o 

o 
6 


_ o 


Eye. 


Age. 


Sex. 


R. 

or 
L. 


Condition 
of eye. 


Condition 
of patient. 


Operation. 


Complications 

at time 
of operation. 




4 


241 

247 

351 
533 

554 

631 

633 

657 

975 

1037 

1114 

1222 

1235 

1304 
1305 
1312 
1436 
1455 

1480 
148 L 
15^6 

1599 
1683 

1696 

1724 

1767 
1797 


2 

1 

1 
2 

1 
1 
1 

1 
1 
1 
1 

2 

1 

1 
1 
1 
1 
1 

2 
1 
1 

1 
1 

1 

1 

2 

2 


66 
73 

65 

47 

68 
64 
73 
62 
67 
28 
79 
66 

70 

65 
66 
68 

78 

77 

49 
70 

78 

66 
61 

65 

58 
65 

28 


F. 

F. 

M. 

F. 

F. 
M. 
M. 
F. 
F. 
M. 
F. 
F. 

F. 

M. 

M. 
F. 
F. 
F. 

M. 

M. 

M. 

F. 
M. 

F. 

F. 
M. 
M. 


L. 

L. 

L. 
L. 

R. 
R. 
L. 
R. 
L. 
R. 
R. 
R. 

R. 

R. 
L. 
L. 
R. 
L. 

L. 
L. 
R. 

R. 
R. 

L. 

L. 

R. 
R. 


Good 

Projection 
bad 

Good 

a 

,, ...... 

)> 

,, ...... 

j> 

JJ 

JJ * 

Iris tremu- 
lous. Pro- 
jection not 
good 

Good 

Good ! 

>? 

>j ...... 

jj 

,, ...... 

Myopic 

Good 

Hypermature 

cataract 
Corneal 

nebula 
Good , 

Good 


Good 

jj ...... 

)> 

jj ...... 

Cough 

Good 

)) 

jj ...... 

Unsteady. . . 
Rheumatic . 
Good 

jj 

Deaf 

Good 

j» 

Feeble 

Good.'.... 

,, ...... 

jj 

Deaf 

Good 

jj 

jj 


Usual operation . 
jj jj 

jj jj 
jj )) 

jj jj 
jj j> 
jj jj 
»> jj 

Scoop extraction. 
Usual operation . 
jj jj 

jj jj 

jj >j 

jj jj 
After prelimin- 
ary iridectomy 
Usual operation . 

jj jj 

j? jj 

JJ jj 

JJ JJ 
J> J> 


None 




5 
6 


Soft matter left 
None 




V 






8 






9 


" 




10 
11 


jj 




12 


JJ 




13 
14 


Soft matter left 
None 




15 






16 






17 






IS 


" 




19 


" 




20 


" 




21 


" 




2'?, 






23 

24 


Soft matter left 
None 




25 

26 






27 






28 
29 


Iris entangled,. 
None 




30 













Hosted by 



Google 



1801] 



RESULTS OF CATARACT EXTRACTION. 



93 



Secondary 
complications. 



Immediate 
result. 



Remote 
result. 



Secondary 
operations. 



Complica- 
tions after 
secondary 
operations. 



Result 
after 2nd 
operation. 



Remarks. 



None 
Iritis, &c. 
None . . . . 



flyphsema 

None 

K. striata. . 
None 



Iritis 

Sympathetic 
ophthalmia 
None 



Hand- 
movement 
6/9 J. 2 
6/6 J". 1 

6/24 J. 2 
6/9 J. 1 
6/9 J. 1 
6/36 
6/24 
6/18 
6/9 
2/60 



6/36 



6/60 
6/24 
6/36 

1/60 * 

6/9 

6/36 

6/18 
6/18 

2/60 



6/24 
6/18 



i J. 1 



6/12 

6/36 

6/60 
6/9 J. 1 

6/30 

6/24 



> J. 1 



6/24 



6/24 
6/9 J. 1 
6/60 J. 10 
1/60 



3/60 
6/24 J. 10 



5/60 
6/24 



Needling 



Needling 



1 Needling 

2 Excision 



Needling 



Needling 



6/24 
6/6 J. 1 



6/6 J". 1 
6/6 J. 1 



6/6 J. 1 



6/60 J. 10 
6/12 



6/18 



6/9 



6/18 



R., No. 1719 (year 

1890). 
Always a defective 

eye. 

R., No. 1768 (year 
1889). 



L., extraction 1887. 
Did well. Vitre- 
ous opacities. 

Sympathetic oph- 
thalmia followed 
extraction. 



Vitreous opacities 
choroiditis. 



L., No. 351. 

L. extracted else- 
where three years 
ago. Bid well. 



Hosted by GoOgle 



94 



ON THE IMMEDIATE AND REMOTE 



[1892 



Hi ® 








R. 


'Ph'SjD 


Eye. 


Age 


Sex. 


or 


CO o 








° 03 











Condition 
of eye. 



Condition 
of patient. 



Operation. 



Complications 

at time 
of operation. 



9 

10 

11 

12 
13 
14 



18 
19 
20 

21 

22 

23 



24 



25 
26 



25 



27 

67 

124 

245 

250 

258 



482 

591 

738 

795 

937 
938 
950 



15 1008 

16 j 1052 

17 ! 1072 



1131 

1276 
1359 

1381 
1530 

1549 



1576 

1592 
1652 



27 1074 



1 


62 


F. 


L 


1 


65 


M. 


R. 


1 


70 


M. 


R. 


1 


65 


M. 


R. 


1 


68 


M. 


R. 


2 


61 


F. 


L. 


1 


62 


F. 


R. 


2 


48 


M. 


L. 


2 


65 


M. 


L. 


2 


72 


F. 


L. 


1 


65 


F. 


L. 


2 


62 


F. 


L. 


1 


70 


F. 


R. 


1 


69 


M. 


R. 


1 


78 


M. 


R. 


1 


33 


F. 


R. 


1 


60 


M 


L. 


1 


79 


M. 


R. 


1 


61 


M. 


R. 


1 


84 


M. 


R. 


1 


65 


M. 


R. 


1 


71 


F. 


L. 


2 


79 


M. 


L. 


2 


72 


M. 


L. 


1 


67 


M. 


r.. 


1 


68 


M. 


R. 


1 


61 


F, 


L. 



G-ood 

j> 

Ch. conjunc- 
tivitis 
Good 

Old iritis . . , 



Iris tremu- 
lous. Lens 
loose 

Ch. conjunc- 
tivitis 

Myopic .... 

Hyper mature 

Grood 

jj ' 

Projection 
bad. Hy- 
pe rmatu re 
cataract 

Good 

j, .... 

5) 

>) 

Brown cata- 
ract 

G-ood 

Projection 
not good 

Good 

Myopic . . . 

Grood 

,, ..... 

Entropion . 



G-ood 

» • 

,, ...... 

?3 

)) 

Paralysis 
agitans 
Good 

j> 

Dyspnoea . . . 

G-ood 

j, ...... 

3J 

•)•) 

Dyspnoea and 
unsteady 

G-ood 



Conjunctival flap 
Small iridec- 
tomy. Capsule 
opened with 
cystotome 

Usual operation . 



None 



Difficult to de 
liver 

Vitreous lost . . . 

None 

Vitreous pre- 
sented 
None 



Hosted by GOOgle 



1892] 



RESULTS OF CATARACT EXTRACTION'. 



95 



Secondary 
coxrrplications. 



[mmedi&te 
result. 



Remote 
result. 



•Slight iritis . . . 



P.S 

None 

[ritis and P.S 
None 

}i 

>> 

,, ....... 

Atropine irrr 
station 

None 

j? 

3) . . . . 

5) * » 

Senile dementia 

Slight iritis . . . 
None 

Vitreous pro- 
lapse 

IS one 

Irritation of 
lids 

None 



6/60 


6/24 
6/18 

6/24 


6/6 J. 1 

6/60 


6/60 


Hand- 


movement 


6/12 


6/12 J. 4 


6/60 


6/24 

6/9 

6/60 J. 12 


6/9 J. 1 


6/24 J. 6 


6/24 


4/60 J. 12 
6/36 


1/60 


6/60 J. 16 


6/24 J. 4 

6/24 


6/60 J. 14 



6/9 J. 1 

6/18 J. 8 
6/24 



1/60 
6/24 

2/60 

6/6 

6/12 J". 1 

6/60 J. 12 

6/12 J. 2 

6/6 

6/60 J. 12 

.6/60 J. 16 

6/12 J. 4 
6/60 

5/60 J. 19 
6/18 

6/24 J. 8 
6/36 J. 15 



1/60 



6/36 J. 3 5 

6/9 J. 1 
6/18 J. 6 

6/36 J. 4 



Secondary 
operations. 



Complica- 
tions after 
secondary 
operations. 



i 



Result 
after 2nd 
operation. 



Remarks. 



Needling 



Capsule 
extraction 
Needling 



1. Iridec- 
tomy 

2. Needling 



Needling 



Needling 

Capsule 
extraction 

Needling 



Yitreous 
lost 



Post sjn. 



Vitreous 

lost. Severe 

iritis 



6/12 J". 8 



6/12 J. 2 
6/6 J. 1 



6/36 J. 8 
6/6 J. 1 

6/18 



6/36 
6/6 J. 1 

6/24 

6/6 J. 1 
6/6 J. 1 
6/12 J. 12 

6/9 J. 1 

Hand- 
movement 

6/9 J. 1 

6/12 J. 4 
6/12 J. 4 



Vitreous opacities. 



R, No. 2255 (year 
1889) 

Cholesterin in vitre- 
ous. R. did badly 
after extraction 
elsewhere. 



R., No. 631 (year 

1891). 
R. extraction in 1887 

did well. 



R., No. 258. 
Vitreous opacities. 



Disc atrophic. 
R,, No. 1131. 
R., No. 67. 



Hosted by VjOOQIC 



96 



ON THE IMMEDIATE AND REMOTE 



23 



29 
30 

31 

32 
33 
34 
35 



[1892-1893 



Ph CD 



Eye. 



Age. 



Condition 
of eye. 



Condition 
of patient. 



Operation. 



Complications 

at time 
of operation. 



1675 



1676 
16S0 

172-1 

1867 
1893 
1900 
1599 



2 


70 


F. 


E. 


1 


34 


M. 


L. 


2 


77 


M. 


L. 


1 


75 


M. 


R. 


1 


68 


F. 


L. 


1 


69 


M. 


L. 


1 


64 


M. 


R. 


2 


62 


F. 


R. 



Myopic. . . . 

Good 

j? 

Old iritis . . 

Good 

,, . . . . , 
>) t . . . . 

Good 

)) 

Ch. conjuno 

tivitis 
G-ood 



G-ood. 



Usual operation 



No iridectomy. . . 
Usual operation . 

After preliminary 

iridectomy 
Usual operation . 



None , 



Slight loss of 
vitreous 



1 


3 


1 


30 


M. 


R. 


2 


10 


1 


57 


F. 


L. 


3 


11 


1 


68 


F. 


R. 


4 


252 


2 


70 


M. 


L. 


5 


296 


2 


75 


M. 


R. 


6 

7 
8 


297 
320 
381 


1 

1 
2 


61 

74 
60 


M. 
M. 
M. 


L. 
L. 
R. 


9 
10 


426 

453 


1 
1 


56 
42 


M. 
F. 


L. 
L. 


11 


705 


1 


59 


F. 


L. 


12 


706 


2 


71 


F. 


L. 


13 


728 


2 


65 


M. 


L. 


14 


734« 


1 


36 


F. 


L. 


15 


839 


2 


64 


F. 


R. 


16 
17 


P45 
864 


1 

1 


73 

Go 


M. 

F. 


R. 
R. 



Good 



Eczema 

face 
Good . . . 



of 



Gouty 



Conj. flap. No 
iridectomy. 
Capsule opened 
with cystotome 

Small iridectomy 



Iridectomy after 

extraction 
Usual operation, 

with iridectomy 



Capsule forceps 

used 
Usual operation, 

with iridectomy 



None 



Soft matter left 
None 



A fter preliminary Soft matter left 
iridectomy [ 



Hosted by GOOgle 



1892-1893] 



RESULTS OP CATARACT EXTRACTION. 



97 





Secondary 


Immediate 


Remote 


Secondarv 


Complica- 
tions after 


Resulk 
after 2nd 
operation. 


Remark s. 




complications. 


result. 


result. 


operations. 


secondary 
operations. 




None 

?? • • 


1/60 

6/9 

6/60 J. 19 

2/60 


1/60 

6/6 J. 1 
6/12 J. 1 


•• 


•• 


•• 


L., No. 41 (year 
1889). R. myopic 
fundus changes. 

R. extracted in 1884 
did well. 




)? * • 


6/60 J. 14 


6/24 J. 12 


Needling 




6/6 J. 1 






,, 


6/18 J. 6 


6/9 J. 4 












,, 


6/36 J. 15 


6/12 J. 2 












Iritis and P.S. 


6/36 J. 14 


6/24 J. 8 






• * 


L. extracted else- 
where. R. capsule. 



None 

>> • • 

Corneal nebula 

None 

>> • • • 

K. striata 

None . . 

}> 

Slight iritis . . . 
None 



6/18 J. 


1 


6/36 J. 


6 


6/36 J. 


12 


6/24 J. 


15 


6/60 J. 


16 


6/18 J. 
6/36 J. 
6/36 J. 


8 

12 

8 


6/12 J. 
6/24 J. 


1 
1 


6/60 J. 


19 


6/30 J. 


14 


6/36 J". 


15 


6/24 




6/24 J. 


6 


624 J". 


6 


6/36 J. 


12 



6/9 J. 1 

6/18 J. 4 

6/24 J". 6 



6/36 
6/12 J. 2 

6/12 J. 2 



3/60 
6/36 J. 12 

6/18 J. 4 
6/12 J. 4 
6/12 J. 4 



2. Needling 



Needling 
Needling 





R. No. 1652 (year 




1892) a little cap- 




side. 




L. extraction 1888. 




Did well. 


6/18 J. 4 






L., No. 1072 (year 




1892). 


6/18 J. 8 


Vitreous opacities. 


6/6 J. 1 


R., No. 938 (year 




1892). 


. . 


R. No. 1276 (year 




1S92). 


•• 


R. healthy. 




L. extracted else- 




where. Did well. 



Hosted by GOOgle 



98 



ON THE IMMEDIATE AND REMOTE 



[1893 



S3 a; 



03 ^S 








R. 


P^'SjO 


Wye. 


Age. 


Sex. 


or 


<n <b 








L. 


£tf 










— i 











Condition 
of eye. 



Condition 
of patient. 



Operation. 



Complications 

at time 
of operation. 



18 


865 


1 


69 


M. 


R. 


19 


866 


2 


68 


M. 


R. 


20 


905 


1 


53 


F. 


R. 


21 


921 


1 


67 


M. 


R. 


22 


935 


2 


78 


M. 


L. 


23 


973 


1 


77 


M. 


L. 


24 


977 


1 


66 


F. 


L. 


25 


991 


1 


69 


F. 


R. 


26 


1036 


1 


55 


M. 


R. 


27 


1054 


1 


77 


F. 


R. 


28 


1209 


1 


64 


F. 


L. 


29 


1210 


1 


52 


F. 


R. 


30 


1220 


1 


60 


F. 


L. 


31 


1238 


2 


70 


F. 


R. 


32 


1239 


1 


33 


F. 


R. 


33 


1343 


1 


57 


M. 


R. 


34 


1379 


I 


65 


F. 


L. 


35 


1380 


1 


60 


F. 


R. 


36 


1396 


1 


68 


F. 


L. 


37 


1413 


1 


64 


M 


L. 


38 


1560 


1 


60 


F. 


R. 


30 


1564 


2 


62 


M. 


R. 


40 


1588 


1 


64 


F. 


R. 


41 


1608 


2 


50 


M. 


L. 


42 


1658 


2 


35 


M. 


R. 


43 


1702 


1 


58 


M. 


L. 


44, 


1758 


2 


54 


F. 


L. 



G-ood 

)> 

55 

)> • 

)) 

)) 

>> 

,, ...... 

Projection 
bad 

Good 

•>■) • 

)j ...... 

>> ' 

jj 

j» -»••••■ 
)) 

>) 

J? 

Myopic. . . . 

Good 

Mucocele. 

Sac dissect 

ed out 
Good 



Good 

>> •*.... 

Feeble. Mit- 
ral disease 

Good 

jj ...... 

») 

Albuminuria 

Good 

Gouty, alco- 
holic 
Good 



Usual operation, 
with iridectomy 



After preliminary 

iridectomy 
Usual operation, 

with iridectomy 

Capsule forceps 
used, with iri- 
dectomy 

Usual operation 



Capsule forceps 
used, with iri- 
dectomy. 

Usual operation, 
with iridectomy 

No iridectomy . . 

Usual operation, 

with iridectomy 



Fluid vitreous 

lost 
None 

i) • • • 

,, ........ 

J) 

» * 

)> » • 

J) * 

}) 

)> 

j) ' 

a 

Soft matter left 
None 

» * * ' 

Fluid vitreous 

lost 

Soft matter left 
None 



Hosted by 



Google 



1893] 



RESULTS OF CATARACT EXTRACTION. 



99 



Secondary- 
complications. 



Immediate 

result. 



Remote 
result. 



Secondary 
operations. 



Complica- 
tions after 
secondary 
operations. 



Result 
after 2nd 
operation. 



Remarks. 



Entropion . . . 
None , 



K. striata 
None 



D. T. 



!STone 

•Slight iritis . . . 



K. striata. 
None . . . . 



6/24, J. 


14 


6/60 J. 


19 


6/24 




6/12 J. 
5/60 J. 


6 
15 


6/18 J. 


12 


6/60 J. 


10 



6/12 J. 12 



6/24 J. 12 

6/24 J. 12 
2/60 

6/24 J. 8 
•i/18 J. 12 

6/12 J. 8 



„ i 6/12 J. 10 

„ i 6/12 J. 1 

Iritis \ 1/60 J. 18 

None I 1/60 



Hyphsema . 
None 



6/60 J. 16 
6/36 J. S 
6/36 J. 6 
6/36 J. 6 



6/36 J. 16 
6/36 J. 15 



6/9 J. 1 
6/18 J. 1 



6/60 



6/18 J. 8 
6/12 

6/60 J. 18 

6/24 J. 14 
6/18 J. 12 

6/9 J. 1 

6/12 J. 8 

6/12 J". 1 
6/36 J. 8 

6/6 J. 2 
6/60 J. 12 



6/36 J". 12 
6/24 J. 6 
2/60 J. 15 

6/6 J. 1 
6/12 J. 1 
6/18 J. 2 



6/12 J. 2 

6/12 J. 4 

6/6 J. 1 
6/12 J. 1 

6j6 J. 2 



Needling 



Needling 



Needling 

Needling 
Paracen- 
tesis 



Needling 



Needling 



Needling 
Needling 
Needling 



Grlaucoma 



6/6 J. 1 



6/24 J. 12 

6/36 J. 15 

6/24 



6/18 J. 2 
6/6 J. 4 



tf/18 J. I 
6/12 J. 1 
6/24 J. 8 



L., No. 1592 (year 
1892). 



K, No. 1008 (year 
1892. L. vitreous 
opacities. 

Vitreous opacities. 



VOL. XIV. 



Capsule. 



L., No. 1312 (year 
1891). 



Vitreous opacities. 



L. extracted else- 
where 15 years 
ago. 



L. operated upon 
nine years ago. 
Did well. 



L., No. 1210. 



H 



Hosted by G00gle 



J 00 



ON THE IMMEDIATE AND REMOTE 



[1889 



^ 










c3 a> 








B, 


£'Sb 


Eye. 


Age. Sex. 


or 


gtf 




1 


L. 


w 











Condition 
of eye. 



Condition 
of patient. 



Operation. 



Complications 
at time of 
operation. 



8 
9 

10 



11 

12 



13 

14 

15 
If 1 
17 
1* 
19 

20 
21 



14 

145 

247 

33f> 

387 

429 



473 
652 

671 



757 



7 8U 

900 



901 

921 

986 
1118 
12-13 
1351 
1392 

1399 
1464 



54 

69 

75 

66 

72 

53 

65 
41 

68 
58 

70 

72 



M 



E. 



Good, 



Projection 
not good 

Morgagnian 
cataract 

Good 

Brown nu- 
cleus. Clear 
cortex 

Brown nu- 
cleus 

Good 

» 

J, ...... 

,, ...... 

)> 

Iris tremu- 
lous. Over- 
ripe dense 
brown cata- 
ract 

Leucoma ad- 
herens 



Brown nu- 
cleus 

Over-ripe . . 
? Secondary 
Good 

Old iritis . . 

Good 



Cough ..... 

Good 

j> 

,, ...... 

,j ...... 

Slight cough 
and un- 
steady 

Alcoholic. .. 
orood 

>> 

,, ...... 

jj .... 

53 ' 

)) 

J3 

)) 

Not noted . . 
Good 



Conjunctival flap. 
Small " iridec- 
tomy. Capsule 
opened with 
cystotome 



No iridectomy 
With iridectomy 



No iridectomy. 
Lens de- 

livered with 
difficulty 

With iridectomy 



With iridectomy. 
Capsule for- 
ceps used 

With iridectomy. 
Peripheral cap- 
sulotomy 

Scoop extraction 



With iridectomy 



No 



iridectomy 



Some soft mat- 
ter left 



With iridectomy. 

Lens extracted 

in capsule 
Usual operation. 

No iridectomy 



None , 



Iris did not go 
well back 



None , 



Vitreous lost. . 



None , 



Hosted by GOOgle 



18S9] 



RESULTS OF CATARACT EXTRACTION. 



101 



Secondary 
complications. 



Immediate 
result. 



Eemote 
result. 



Secondary 
operations. 



Complica- 
tions after 
secondary 
operations. 



Result 
after 2nd 
operation. 



Remarks. 



None . 



2 post syn.. . 
Prolapse of iris 



None 

Atropine irrita- 
tion 

Membrane in 
pupil 



None 

Much, iritis . . . 

Suppura 



Iritis 



Post synechias. 
Struck eye. . 
Severe iritis . . 

Post synechias. 
Slight iritis . . . 



6/60 J. 19 

J. 16 

5/60 J. 16 



J. 20 
5/60 J. 19 



3/60 J. 20 
3/60 



6/60 
6/6 J. 1 



tion 



3/60 J. 20 



6/60 

Fingers at 
12" 



6/60 



5/60 J. 16 

6/18 J. 1 
6/12 J. 1 



6/9 J. 1 

1/60 

6/18 
5/60 
6/12 J. 1 



6/24 J. 6 



Capsule 
extraction 



1 Iridec- 
tomy 

2 Evisce- 
ration 



Paracen- 
tesis 



Eviscera- 
tion. 



Capsule 
extraction 
Needling 



Needling 



Needling. 



Iritis 



- vitreous 
lost 



6/24, J. 4 



6/12 
6/18 J. 6 



13 J< 8 



6/18 J. 2 



Patient coughed 
much during the 
1st night after ex- 
traction. 

R. did well. 



L. did well. 2nd 
operation done for 
tensionj w hich 

= lh 
L. did well. 



E. did well. 



E. lost after small- 
pox. Extraction 
done under chloro- 
form. 



L. quite healthy. 



Anaesthetic — ether 
and chloroform. 



H 2 



Hosted by 



Google 



102 



ON THE IMMEDIATE AND REMOTE 



[1889-1890 



tn o 









E. 


Eye. 


Age. 


Sex. 


or 
L. 



Condition 
of eye. 



Condition 
of patient. 



Operation. 



Complications 

at time 
of operation. 



22 
23 

24 

25 



1510 
1657 

1765 

1766 



26 
27 
28 
29 
30 
31 
32 
33 
31 

35 ; 2273 

36 2291 

37 i 2323 

i 



1795 
1S02 
2050 
2063 
2034 
2065 
3173 
2186 
2212 



1 


70 


M. 


E. 


1 


74 


F. 


L. 


2 


59 


F. 


R. 


2 


64 


F. 


L. 


1 


70 


ML 


L. 


2 


72 


F. 


L. 


1 


59 


M. 


E. 


2 


42 


F. 


L. 


1 


63 


M. 


L. 


1 


75 


M. 


E. 


1 


73 


F. 


E. 


1 


86 


F. 


L. 


1 


58 


M. 


E. 


1 


62 


F. 


L. 


1 


35 


M. 


L. 


1 


71 


F. 


L. 



Good 

Ch. conjunc- 
tivitis 



Good , 



Good 

Weak 

Good 

Not noted . . 

Good 

JJ 

JJ 

Good 

jj 

jj 

Eheumatie . 
Good ...... 



With iridectomy 

Incision enlarged 
Iridectomy 



No iridectomy 
With iridectomy 



No iridectomy 



With iridectomy 



None 

?) • ♦ • • 

n 

Globe very 

flaccid, soft 
matter left 

None 

Soft matter lei t 

None 

j? 

jj 

Soft matter left 
None 

None 

jj 

JJ .... o ... . 

Vitreous lost. . . 
None 

Soft matter left 
None 



6 


1 


37 


F. 


L. 


56 


1 


45 


M. 


E. 


72 


1 


63 


M. 


E. 


237 


1 


71 


M. 


E. 


353 


1 


65 


F. 


E. 


428 


1 


68 


F. 


L. 


327 


2 


37 


M. 


L. 


438 


2 


70 


M. 


E. 


606 


1 


54 


M. 


E. 



Good . 



Hyper mat ure 
cataract 

Old iritis, 
and colo- 
boma down 
and in 

Good 



Conj unctival flap. 
Small iridec- 
tomy. Capsule 
opened with 
cystotome 

After preliminary 
iridectomy 

Usual operation 
with iridectomy 

Scoop extraction 
after iridec- 
tomy 

Extraction up- 
wards after a 
fresh iridec- 
tomy 

No iridectomy 

With iridectomy 

No iridectomy 



Hosted by GOOgle 



1889-1890] 



RESULTS OF CATARACT EXTRACTION. 



103 













Complica- 


Result 






Secondary 


Immediate 


Remote 


Secondary 


tions after 


after 2nd 


Remarks. 




complications. 


result. 


result. 


operations. 


secondary 
operations. 


operation. 






None 


6/24 




•• 


•• 


•• 


L. excised for trau- 
matic ulcer. 




Slight iritis . . . 


•• 


Hand' 
movement 


Needling 
Iridotomy 


Some iritis 

after 
iridectomy 


P. L. 






None 


1/60 
6/6 J. 1 


6/24 


Needling 2 


None 


6/9 J. 1 


L. did well after 
severe iritis. No. 
1392. 

R. did well after 
extraction. 




Slight iritis. 
















None. 


6/60 J. 12 
618 J. 6 


2/60 


Needling 


•' 


6/18 J. 6 


R. did well, No. 1464. 







1/60 


6/24 J. 12 


Needling 


None 


6\6 J". 1 


R. did very well. 




,, 


6/18 J. 12 






, . 




Vitreous opacities. 




n 


6/36 J. 14 


6/12 J". 4 












Some iritis. . . . 


4/60 J. 15 
6/6 J J. 18 


6/6 J. 1 












None 


6/2 1 J. 12 

6/24 


6/6 J. 1 












» 


2,60 


2/60 


Needling 


None . 


•• 


Still some unab- 
sorbed lens matter. 




» 


3/60 J". 18 


6/18 J. 8 


Needling 


jj 


6/6 J. 1 





None 



Some iritis and 

P.S. 
None ..... 



Iritis 



None , 



1/60 J. 20 

6/24 
2/60 
1/60 

1/60 



6/6 
6/12 
4/60 
6/12 J. 1 



1/60 J. 20 



2/60 J. 19 
1/60 



Hand- 
movement 



6/18 

6/60 ' 
6,18 



Needling 



Needling 
Needling 



Needling 

Needling 
Needling 



None 



6/12 J. 1 



6/6 J. 1 
6/6 J. 1 



6/6 J. 1 

6/6 J 1 
6/12 J, 1 



Vitreous opacities. 



R. did well. 
L. did well. 



Hosted by G00gle 



104 



ON THE IMMEDIATE AND REMOTE 



[1890 



r— 1 O 

c3 -^ 






E. 


■s/S> F? e - 

CO O 


Age. 


Sex. 


or 
L 


,9 Pm 








w 1 









Condition 
of eye. 



Condition 
of patient. 



Operation. 



Complications 

at time 
of operation. 



10 


613 


1 


65 


F. - 


E. 


n 

12 


65& 
692 


1 

2 


60 
61 


M. 

F. 


E. 
L. 


13 


807 


1 


27 


F. 


L. 


14 
15 
16 


906 
1012 
1046 


1 
1 
1 


72 
52 
62 


F.\ 

F. 

F. 


L. 
L. 

L. 


-17 


1071 


2 


m 


F. 


E. 


18 


1073 


1 


55 


F. 


L. 


19 
20 


1199 
1269 


1 
1 


74 
76 


M. 
M. 


E. 


21 

22 


1274 
1337 


1 
1 


56 
76 


F. 
M. 


E. 
L. 


23 


1354 


2 


65 


F. 


E. 


24 


1369 


1 


75 


F. 


E. 


25 

2ij 

21 


13S4 
1400 
1417 


1 
1 
1 


74 
72 
7S 


F. 
F. 
F. 


E. 
L. 
L. 


28 


1436 


1 


78 


M. o 


E. 


29 
30 


J4S0 
1533 


2 
2 


65 
65 


F. 

F. 


E, 
L. 



Good ...... Good No iridectomy . . 



Proj ection 

bad 
Good 



Dislocated 
lens trau- 
matic 



Good 



Incomplete 
cataract 



Good 



Myopia and 
fundus 
changes. 
Dark brown 
cataract 

Incomplete 
cataract, 
amber co- 
loured 

Good 



Diabetes. . , 



Good 

Bad health . 



Good , 



Diabetic . 
Good . . . 



Unsteady 
patient 



Good 



6coop extraction 
and no iridec- 
tomy 
No conjunctival 
flap after prelimi- 
nary iridectomy 
Usual operation. 
No iridectomy 

After preliminary 
iridectomy and 
artificial ripen- 
ing 

N o iridectomy 

With iridectomy 
after attempt 
"without 

After preliminary 
iridectomy 

Attempt without 
iridectomy ; 
finally iridec- 
tomy done 

No iridectomy 

With iridectomy 



After preliminary 
iridectomy and 
artificial ripen- 
ing _ 
No iridectomy 
Extracted with- 
out iridectomy. 
Then iridec- 
tomy done. 



None , 



Pt. unsteady. 
Vitreous lost . 



None , 



A good deal of 
vitreous lost 



None . 



Soft matter re- 
mained 



Iris torn and 
bruised by lens 



Hosted by GOOgle 



1890] 



RESULTS OF CATARACT EXTRACTION. 



105 



Secondary 
complications. 



Lritis and hy- 
phema after 
blow 

None 

5) • * 

Iritis 

None 

?) 

j> 

]£. striata 

Iritis 

jj 

Slight iritis .. . 

35 J) • • • 

None 



Immediate 
result. 



Remote 
result. 



616 J. 1 



6/12 
6/18 

Hand- 
movement 
6/36 J. 12 

6/12 J. 1 



6/9 J. 1 



6/9 J. 1 

4/60 
6/12 J. 1 



6/12 J. 2 
6/60 



1/60 
6/24 



6/18 
3/60 
1/60 



1/60 



6/60 



6/36 



6/36 
4/60 

Fingers at 

18" 
6/24 J. 2 
6/60 
6/6 J. 1 



4/60 



6/6 J. 1 



6/9 J. 4 



i J. 1 



4/60 
1/60 



1/60 



Secondary 
operations. 



Complica- 
tions after 
secondary 
operations. 



Needling 



Needling 
Needling 

Needling 



Needling 



None 



Result 
after 2nd 
operation. 



i J. 1 



6/6 J. 1 
6/6 J. 1 

3/60 



Hypopyon 

and 

vitreous 

opacities 



2 Needling 
Needling 



Needling 
sclerotomy 



None 



Glaucoma 

and 

vitreous 

opacities 



/12 J. 1 
/60 J. 20 



1/60 



. Remarks 



Some fundus changes 

in R. 
Yitreous opacities. 

Yitreous opacities. 



L. did fairly well. 



L. lost after cata- 
ract extraction and 
excised. 



Choroidal atrophy. 



L. did well. 
R. did well. 



Hosted by G00gle 



1C6 



ON THE IMMEDIATE AND REMOTE 



31 



33 

34 



35 



Eye. 



Age. 



Condition 
of eye. 



Condition 
of patient. 



Operation. 



1604 


1 


66 


F. 


L. 


1620 


2 


83 


M. 


R. 


1785 


2 


74 


E. 


L. 


1786 


2 


72 


E. 


R. 


1803 


1 


79 


E. 


L. 



Good .... 
Hypermature 
cataract 

Good .... 



Myopia cho- 
roiditis 



Grood ...... 

Mentally de 
ficient 

Good 



With iridectomy 
No iridectomy 



With iridectomy 



After preliminary 
iridectomy and 
artificial ripen- 
ing 



[1890-1891 



Complications 

at time 
of operation. 



None ......... 

Iridectomy done 
after lens re- 
fused to move 
without 

None 



1 


86 


1 


56 


E. 


L, 


2 


194 


1 


60 


M. 


L. 


3 


254 


1 


41 


E. 


L. 


4 


313 


1 


74 


E. 


R. 


5 


315 


2 


66 


E. 


R. 


6 


383 


1 


41 


E. 


L. 


7 


384 


2 


78 


E. 


B, 


8 


398 


1 


50 


F. 


L. 


9 


4u0 


1 


58 


M. 


L. 


10 


401 


2 


60 


M. 


L. 


11 


458 


2 


72 


E. 


R. 


12 


547 


1 


30 


E. 


R. 


13 


577 


2 


4] 


F. 


R. 



Incomplete 
cataract 



Good 

Old intersti 

tial X. 
Good 

,, . . . . . 

Myopic . . . 

Good 

Brown lens 
Good 

Old intersti' 
tial K. 



Good 


Conjunctival flap. 
After prelimin- 


None , 






Gouty 


ary iridectomy. 

Capsule opened 

with cystotome 

With iridectomy 

No iridectomy. . . 

With iridectomy 

>3 33 

No iridectomy. . . 
With iridectomy 




53 

Deaf 

Good 


Soft lens matte i 
left 

None 






,, ...... 


» ••••••••• 




No iridectomy. . . 

J) 33 ' • • 




Unsteady. , . 


Soft matter left 


Good 


33 33 . • • • 






With iridectomy 


None 




Corneal section. 

No iridectomy 

With iridectomy 













Hosted by GOOgle 



1890-1891] 



RESULTS OF CATARACT EXTRACTION. 



107 



Secondary 
Complications. 



Immediate 
result. 



Remote 
result. 



Secondary 
operations. 



Complica- 
tions after 
secondary 
operations. 



Result 
after 2nd 
operation. 



None 

Entropion .... 
None 

K. striata 

Attack of gout 
None 

Hyphaema, &c. 

None 

Prolapse of iris. 
Acute rheuma- 
tism 

None 

Broad ant. syn. 
None 



6/24 
6/36 



6/24 J. 10 
4/60 



6/24 J. 6 



; J. l 



6/60 



6/6 J. 1 
6/18 J. 4 



Needling 



6/36 



Remarks. 



L. failed from optic 
atrophy. There are 
vitreous opacities 
inR. 

R. did well. 

L. did well. 



R. cornea nebulous. 
Yision rery dim in 
1895. 



6/12 



6/18 
6/36 



6/24 J. 10 

6/24 
1/60 



Fingers at 
12 7/ 



6/36 

6/24 



6/6 J. 1 

6/6 J. 1 
1/60 J. 20 



6/24 



i J. 1 



3/60 
6/12 
6/18 



1. Iridec- 
tomy for 
prolapse 

2. Needling 

3. Irido- 
tomy 



Needling 



Followed 
by hypo- 
pyon 



6/6 J. 1 



6/18 J. 4 



Old choroiditis. 



L., No. 1604 (year 
1890). 

L., No. 1417 (year 
1890) R. and L. 
fundus changes, 
choroiditis, &c, 



R., No. 655 (year 

1890). 
L., No. 2323 (year 

1890). 



L., No. L'54. R, 
fundus changes. 



Hosted by GOOgle 



108 



ON THE IMMEDIATE AND REMOTE 



[1891 



"a," So 



itf 



Eye. 



Age. 



Sex. 



Conditio n 
of eye. 



Condition 
of patient. 



Operation. 



Complications 

at time 
of operation. 



14 
15 



16 



18 



19 



20 
21 



22 



23 

24 
25 



26 

27 

28 



29 
30 
31 
32 



611 

658 



659 



674 



768 



S49 

864 
877 



885 



914 

933 
936 



1044 
1045 

1070 



1092 
1137 
1218 
1257 



62 
63 


F. 
F. 


L. 
R, 


56 


M. 


L. 


74 


M. 


R. 


62 


F. 


R. 


70 


F. 


R. 


60 

58 


M. 
F. 


R. 
R. 


56 


M. 


R. 


54 


M. 


R. 


56 
69 


F. 
F. 


L. 
R. 


44 
63 


F. 

F. 


L. 
L. 


70 


M. 


L. 


63 


F. 


R. 


76 


M. 


L. 


66 


M. 


L. 


70 


F. 


L. 

i 



Good .... 
Shrunken 
lens 



Good , 



Epiphora . 



Myopic 



Good , 



Tremulous 
iris 

Good .... 



Conjunct- 
ivitis 
Not good . . 



Good . 



Hrpermature 
cataract 



Good 



Unsteady. . 



Gcod 

Unsteady . . 

Cough 

Good ! 



No iridectomy. . . 
Iridectomy after 

iris was torn by 

lens 
After preliminary 

iridectomy and 

artificial matu 

ration 
No iridectomy. , , 



After preliminary 
iridectomy and 
artificial matu- 
ration 

Iridectomy after 
extraction 

No iridectomy. . . 

Usual operation 
after prelimin- 
ary iridectomy 
and artificial 
maturation 

With iridectomy. 
Scoop extrac- 
tion 

No iridectomy. . . 



With iridectomy 



No iridectomy. . . 
With iridectomy 



None 

)> • • • 

Soft matter and 
capsule 

None 

33 • ' ♦ • 

33 • . . 

3 3 • • • 

Yitreous lost. . . 

None «... 

Cornea flaccid. 
None 

Scoop extrac- 
tion. Yitreous 
lost. Capsule 
removed with 
forceps 

Lens matter left 

None 



Iridectomy after 
extraction. Iris 
split 



Hosted by GOOgle 



:89T] 



RESULTS OF CATARACT EXTRACTION. 



109 



Secondary 
complications. 



Immediate 
result. 



.Remote 
result- 



Secondary 
operations. 



Complica- 
tions after 
secondary 
operations. 



Result 
after 2nd 
operation. 



Remarks. 



None 

Iritis 

None . . . 

K. striata .... 
None 

Iritis and P. S. 

None 

Some post syn. 
and iritis 



Prolapse of 
vitreous 

Prolapse of iris 

Iritis and P. S. 
Prolapse of iris 



None 

Prolapse of 
vitreous 

Entropion .... 

Atropine de- 
lirium 
None 



6/18 J. 12 
2/60 J. 20 



P. L. 



3/60 

6/6 
3/60 

6/60 



6/18 J. 
6/36 



6/60 
6/12 

3/60 



Hand- 
movement 
3/60 

6/36 

6/18 



6/18 
6/9 



1/60 
Hand- 
movement 



6/60 



6/36 J. 10 



Fingers at 

12" 
6/18 



Needling 



Needling. 

Capsule 

extraction 

Needling 



Needling 
Needling 
and cap- 
sule ex- 
traction 



Prolapse 
returned 

1. Iridec- 
tomy for 
prolapse 

2. Needling 
Needling 



Yitreous 
prolapse 
removed 



Capsule ex 
traction 



6/9 J. 1 



6/9 J. 1 



6/9 J. 1 



6/60 J. 8 



6/12 J. 1 
6/12 J. 1 



6/12 J. 1 



6/18 J. 1 
6/6 J. 1 



6/6 J. 1 



Vitreous opacities. 
Disseminated 
choroiditis. 



L., No. 428 (year 
1890). 

Still lens matter. * 



Vitreous full of 
opacities. 



L., No. 1046 (year 

1890). 



Hosted by G00gle 



no 



ON THE IMMEDIATE AND REMOTE 



[1891-1892 



fH 










r— 1 <D 

c3 ■+£ 








R. 


"o. QJD 


Eye. 


Age. 


Sex. 


or 










L. 



Condition 
of eye. 



Condition 
of patient. 



Operation. 



Complications 
at time of 
operation. 



33 


1273 


1 


59 


F. 


L. 


31 


1389 


1 


68 


F. 


L. 


35 


1407 


1 


64 


F. 


L. 


36 


1473 


2 


42 


F. 


R. 


37 


1474 


1 


64 


F. 


R. 


38 


1502 


1 


72 


F. 


L. 


39 


1543 


2 


78 


F. 


L. 


40 


1756 


1 


59 


F. 


R. 


41 


1776 


1 


81 


M. 


L. 


42 


1800 


1 


62 


M. 


R. 


43 


1801 


2 


62 


NL 


R. 


44 


1874 


1 


59 


F. 


L. 



aood 

Old iridec- 
tomy 

downwards 
for iritis 

Hvpermature 
cataract 

aood ...... 

J, ...... 

K. P. and old 

iritis 
Good 

J5 

Good , 

n c 

Morgagnian 
cataract 

Good 

Myopic .... 
Good 



Good . . 
Goitre , 
Good . . 



Ch. bronchi- 
tis 

Good 

Gouty 

Not good . . . 



No iridectomy . . . 

Iridectomy after 
extraction 

Section down- 
wards 



No iridectomy. . . 
>> j> • • • 

JJ 3) ' • • 

J) )) • • * 

With iridectomy 
No iridectomy. . . 



Difficult to ex- 
tract 
None 

Vitreous lost. . . 

None 

,, .......... 

Soft matter left 

None 

Iridectomy after 

extraction 
None 

j> 

Soft matter left 

None 



3 


23 


2 


57 


M. 


R. 


2 


34 


1 


66 


M. 


R. 


3 


43 


1 


57 


F. 


Rv 


4 


62 


1 


64 


F. 


L. 


5 


81 


1 


47 


M. 


L. 


6 


86 


1 


58 


F. 


R. 


7 


127 


1 


58 


M". 


L. 


8 


268 


1 


54 


M. 


L. 


9 


322 


1 


61 


M. 


R. 


10 


381 


1 


74 


M. 


L. 


11 


404 


1 


•10 


M. 


R. 


12 


474 


1 


£0 


M 


L. 



Good . 



Rheumatic 
Good 



Conjunctival flap. 
No iridectomy. 
Capsule opened 
with cystotome 



Iridectomy after 
extraction 

Scoop extraction. 

Iridectomy 

after extraction 

With iridectomy 

No iridectomy . . 



Hosted by GOOgle 



.891-1892] 



RESULTS OF CATARACT EXTRACTION. 



Ill 



Secondary 
complications. 



Immediate 
result. 



Remote 
result. 



Suppurative 

iritis 
None 



Slight iritis. . . 



Prolapse of iris 



None 

Prolapse of iris 



None . 



1/60 
6/12 
4/60 

6/24 

6/9 J. 1 

6/12 



Hand- 
movement 
6/18 



4/60 

6/24 
6/60 
3/60 



6/60 
6/24 
6/60 



6/12 
6/9 



Secondary 
operations. 



Complica- 
tions after 
secondary 
operations. 



Results 
after 2nd 
operation. 



Remarks. 



6/12 
6/24 J. 10 



Capsule 
extraction 
Needling 



Iris re- 
placed 

Iridectomy 
for pro- 
lapse 



Needling 



6/12 J. 1 
6/12 J. 1 



i J. 1 

i J. 1 



L., No. 383. 



R., No. 1369 (year 
1890). 



Lens matter present. 
L., No. 194. 



Hyphasma . . 



None , 



Hyphema 
None , 



Prolapse of iris 



6/12 


6/12 


Needling 


•• 


6/6 J. 1 


6/12 
6/12 
P.L. 


6/6 J. 1 








Hand- 
movement 


Hand- 
movement 


Needling 




Hand- 
movement 


6/24 


4/60 








6/18 
6/12 
6/12 


6/9 J. 6 

6/60 
6/12 


Needling 
2 Needling 
Needling 


•• 


6/6 J. 1 

H/9 

6/18 


Hand-m 


ovement 


Needling 


•. 


6j6 J. 1 


6/12 


6/6 J. 1 


Iridectomy 
for pro- 
lapse 







L. } No. 659 (year 
1891). 



No note as to why 
Y. is so had 

R. lost in infancy. 
Capsule still pre- 
sent. 

Yitreous opacities 
and glaucoma. 



Shreds of capsule 
present. 



Hosted by GOOgle 



112 



ON THE IMMEDIATE AND REMOTE 



[1892' 



05 












03 


£-1 








R. 


o 


So o 


Wye. 


Age. 


Sex. 


or 
Ti 


o 


o pq 










fc 


h-H 











Condition 
of eye. 



Condition 
of patient. 



Operation. 



Complications 

at time 
of operation. 



13 
14 
15 

36 
17 



18 



19 
20 

21 
22 
23 



24 
25 
26 

27 

28 

29 

30 
31 

32 

33 

34 



35 

36 

37 

38 
39 



638 
672 
675 

677 
702 



744 



821 

843 

876 
889 
877 



890 
946 
947 
965 

1065 

1081 

108.S 
1101 

1126 

1129 

1214 



]242 
1307 
1326 

1465 



50 



M. 



F. 
F. 
F. 
M. 

M. 

M. 

M. 

M. 

F. 
F. 
M. 



M. 
F. 
F. 

M. 



Gooi.... 

,, .... 

Epiphora . 

Good .... 
,, .... 

,, -.-. . . 

Myopic .. 
Good .... 

j, .... 

Myopic .. 
Good .... 

j, . • . . 

,, .... 

,, .... 

,, .... 

Hy perm ature 

cataract 
Good .... 

33 • • • • 

Corneal 
nebula 
Good .... 

,, . • • • 

„ .... 

Corneal 

nebulae 
Corneal 

nebula 
Good.... 



Good 

Gouty 

Good 

jj 

)> 

j? 

,, ..... 

Feeble .... 

Good 

)j 

Not good . . . 

Good 

j, ...... 

Feeble 

Good 

Deaf 

Alcoholic . . 
Good 

,j ....... 

Cough 

Deaf and 
dumb 

Good"..'.... 



No iridectomy . . 

3) 3> 

With iridectomy 

No iridectomy . . 
Iris much bruised. 

Iridectomy after 

extraction 
No iridectomy . . 



Iridectomy after 
extraction 



No iridectomy . . 



With iridectomy 



After prelimi- 
nary iridectomy 
With iridectomy 



No iridectomy , 



With iridectomy 



None 

>' 

j> • * 

jj • * 

3 j .... . . 

' >3 

)j • ; 

Iris split ....... 

None 

33 • • 

33 

Iris fell before 

knife 
None 

3 3 

3> 

Vitreous lost. , . 

None 

» 

33 • • 

33 

>3. 

Iris buttonholed 



Hosted by 



Google 



RESULTS Op' CATARACT EXTRACTION. 




113 



Secondary 
operation.* . 



Complica- 
tions after 
secondary 
•perations 



Result 
after 2nd 
operation. 



Bemarks. 



Needling 



Iridectomy 
for pro 
lapse 



1 Iridec- 
tomy for 
prolapse, 
2 need- 
ling 

Needling 

jj 

2 Needling 



Needling 



Needling 



1. Iridec- 
tomy for 
prolapse. 

2. Excision 



Needling 



6/12 J. 1 



6j6 J. 1 



6/12 
6/24 
6/12 J. 2 



6j6 J. 1 



6/9 J. 1 



Much capsule pre- 
sent. 



6/6 J 1 



L. No. 677. 
Outer angle re- 
mained entangled 



Much lens matter 

and capsule 
L., No. 1502 (year 

1891). 



Hosted by G00gle 



114 



ON THE IMMEDIATE AND 



u 










r— 1 <x> 

3 +1 








R. 


'ji/Sb 


Eye. 


Age. 


Sex. 


or 
T, 


o aq 










=1 











Condition 
of eye. 



Condition 
of patient. 



40 


14S7 


2 


74 


F. 


L. 


41 


1552 


2 


72 


M. 


L. 


42 


175L 


1 


51 


M. 


L. 


43 


181 L 


2 


59 


F. 


R. 


44 


1829 


1 


62 


M. 


R. 


45 


1885 


1 


2y 


F. 


L. 



Lac. obstruc- 
tion 



None 



Good 



Mucocele . 



1 


95 


2 


77 


M. 


2 


210 


1 


35 


M. 


3 


211 


1 


36 


M. 


4 


236a 


1 


56 


F. 


5 


243 


2 


76 


M. 


6 


327 


1 


68 


M. 


7 


350 


1 


70 


F. 


8 
9 


373 
413 


2 
1 


62 

74 


M. 
M. 


10 
12 


417 
539 

579 > 


1 

1 
1 , 


40 
66 
59 


F. 
M. 
M. 



L. 

R. 

R. 

L. 
L. 

R. 
R. 



L. 

L. 



R. 
L. 
R. 



Good, 



Projection 
bad. T + 

Myopic, &c. 



Ch. conjunc- 
tivitis 

Regurgita- 
tion from 
sac. Pro- 
jection not 
good 

Good 



C. nebulous Rheumatic 

G-oed ! Good 

„ , , Cough 




Good . . 



Alcoholic 
Good . . . 



Extremely 
infirm, Rh 
arthritis 

Good 



Hosted by GOOgle 



1892-1893] 



RESULTS OF CATARACT EXTRACTION. 



115 













Complica- 


Result 






Secondary 


Immediate 


Remote 


Secondary 


tions after 


after 2nd 


Remaiks. 




complications. 


result. 


result. 


operations. 


secondary 
operations. 


operation. 






Slight iritis . . . 


6/18 


•• 


•• 




•• 


R. extracted eight 
years ago. Did 
■well. 




55 * * ' 


6/36 J. 12 


6/24 J. 10 








R. extracted six 
years ago. Bid 
well. L. vitreous 
opacities. i 




Iritis 


6/12 J. 1 














None 


6/18 J. 1 


•• 


•• 




•• 


L., No. 1875 (yeal 
1891). I 




Post. Syn 


6/24 


6/12 J. 6 












Prolapse of iris 






Iridectomy 
for pro- 
lapse 









None 



None , 



Entropion .... 
Some P. S. . . . 



None 

Rh. arthritis . . 



None 

Prolapse of iri> 



None , 



6/36 J. 14 



B"and- 
movement 



1/60 



Fingers at 
12" 

2/60 



6/18 J. 12 



6/36 J. 14 
6/18 J. 12 



6/60 J. 19 
6/9 J. 1 
6/9 J. 6 



6/24 J. 8 



1/60 



6/24 J. 6 



6/12 J. 1 



Needling 



Needling 2 



Iridectomy 
for pro- 
lapse 



Outer 

angle re- 
mained 
entangled 



> J. 2 



6/36 J. 15 



6/12 J. 6 j Needling 



R., No. 1465J 
1892). 



Choroid 1 

and T]J 

cities 
L. totaj 

chiae. 

atropll 
Capsule 

matte J 
R,, No* 

1891). 



Choroidal aj 

&c. 
JR., No. 

1892). 



VOL. XIV* 



6/12 J. 6 j Vitreous opacitl 



Hosted by G00gle 



116 



ON THE IMMEDIATE AND REMOTE 



[1893 



S3 













—3 G> 

53 -+3 








K. 


"pL'Ejd 


Uye. 


Age. 


Sex. 


or 










L 


°^ 










3 











Condition 
of eje. 



Condition 
of patient. 



Operation. 



Complications 

at time 
of operation. 



60 
51 

56 

61 

47 

66 
70 



M. 
M. 

M. 

F. 

M. 
F. 

M. 

F. 
F. 

F. 
M. 

M. 

F. 

M. 
F. 

M. 

F. 



G-ood 

j> ...... 

Ch. conjunc- 
tivitis and 
blepharitis 

Good 

j, ...... 

Epiphora . . . 
G-ood 

75 

Projection 

bad 
Good 



Good 

Feeble 
Good 

Unsteady. . 
Good ..*.... 

Unsteady . . , 
Alcoholic . . 

Good 

Ch. rheuma- 
tism 
Good 

v 

Goitre .... 
Good 

Cough. .... 
Good 



With iridotomy 
No iridectomy . . 



With iridectomy 
No iridectomy . . 



Scoop extraction 
with iridectomy 

Iridectomy after 
extraction 

With iridectomy 

No iridectomy . . 



With iridotomy 
No iridectomy . . 



With iridectomy 

Scoop extraction 
No iridectomy . . 



With iridotomy 
No iridectomy . . 

With iridectomy 



None 

Iris difficult to 

replace 
Lens difficult to 

d eliyer 
None 

j> . . • • 

Lens matter left 

Vitreous lost. . . 

None 

Soft matter 

None 

Soft matter left 
None 



Hosted by 



1893] 



RESULTS OP CATARACT EXTRACTION. 



117 



Secondary 
complications. 



Immediate 
result. 



Remote 
result. 



Secondary 
operations. 



Complica- 
tions after 
secondary 
operations. 



Result 
after 2nd 
operation. 



Remarks. 



None 

Atropine irrita- 
tion 

None 

Severe irido- 
cyclitis . 
None 

}> 

)> 

)> • * • 

>s 

Prolapse of iris 



Iritis and glau- 
coma 

None 

Ant. syn 

Atropine irrita 

tion 
None 



6/60 J. 
6/12 J. 


16 
1 


6/36 JT. 


16 


6/24 J. 


12 


6/18 




6/12 J. 12 
Fingers at 
4" 


1/60 




6/36 J. 


6 


1/60 
Fingers 

12" 
6/12 J. 
6/12 J. 


i at 

6 
12 


6/24 




6/24 J. 


14 


4/60 J. 


20 


6/18 J. 
6/12 J. 


2 

2 


6/24 J. 
6/24 J. 


12 
16 


6/18 J. 
6/60 J. 


1 
15 


Fingers 

6" 
6/24 J. 


at 
16 



6/18 J. 4 
6/6 J. 1 

6/9 J. 1 

6/6 J". 1 



6/24 

6/9 J. 4 
Hand- 
movement 



Hand- 
movement 
6/9 J. 1 

6/12 J". 1 
Hand- 
movement 
6/12 J. 4 
6/18 J. 6 



6/6 J. 1 
6/36 J. 8 

6/12 J. 1 

6/18 J. 6 
6/6 J, 1 

6/12 J. 1 
6,12 J. 1 



Needling 



Needling 

Needling 
Needling 



Iridectomy 
for pro- 
lapse 



1 Paracen- 
tesis 

2 Needling 

Division 
of ant. 
synechia 



6/Q 


L., No. 1044 (year 
1891). Illiterate. 


Hand- 


L. operated upon 
elsewhere 6 years 
ago. Did well. R. 
lens matter re- 
mained. 

Lens matter still 


movement 


present. 


Hand- 


L., No. 719. 

Lens matter still 


movement 
6/12 J. 4 


present. 



6/24 J. 8 



6/12 J. 1 



L., No. 1751 (year 
1892). 



Vitreous opacities. 



L., No. 1065 (year 
1892). 



Lens matter still 

present. 
R., No. 579. 



Hosted by G00gle 



118 



ON THE IMMEDIATE AND REMOTE 



[1893-1889 



fc 



*- 














R. 


u-a, ^ 


Age. 


.Sex. 


or 


m © 






L 


,9 P=l 








w 1 









Condition 
of eye. 



Condition 
of patient. 



Operation. 



37 


1530 


1 


60 


M. 


E. 


38 


1552 


1 


60 


M. 


R. 


39 


1553 


1 


78 


M. 


L. 


40 


1607 


•• 


60 


•• 


•• 


41 


1633 


2 


36 


M. 


L. 


42 


1655 


1 


63 


M. 


L. 


43 


1692 


1 


57 


F. 


L. 


44 


1731 


2 


60 


F. 


R. 


45 


1732 


2 


55 


F. 


R. 


46 


1753 


1 


46 


M. 


L. 


47 


1821 


1 


67 


?■ 


L. 



Corneal 
nebula, old 
iritis and 
coloboma 
down 

Good 

Corneal 

nebula 
Old iritis 

(coloboma 

down) 
Good „♦.... 

Corneal 
nebula 
Good 

>) * 

Projection 
bad 

Old iridec- 
tomy for 
glaucoma 

Good 



Good 

Alcoholic . . . 
Good 

>) 

Alcoholic. . . 
Good 

Alcoholic. . . 

Lunatic and 

alcoholic 
Good 

Albuminuria 



Extraction down- 
wards. Scoop 



No iridectomy . . 
With iridectomy 

Extraction down- 
wards. Scoop 
extraction 

No iridectomy. . . 



With iridectomy 
No iridectomy . . 

With iridectomy 



Complications 

at time 
of operations. 



"Vitreous lost . . . 



None , 



Fluid vitreous 
lost 



None , 



15 


•• 


47 


F. 


R. 


18 




60 


M. 


R. 


20 


•• 


66 


M. 


L. 


78 


, , 


69 


F. 


R 


108 


•• 


66 


F. 


R. 


136 


t , 


02 


M. 


R. 



Proj ection 
bad 



Good .... 

Myopia — 7'0 
D. Incom- 
plete cata- 
ract 

Bad projec- 
tion 

Bad projec- 
tion 



Good 



Good , 



Corneal section. 
Capsule forceps 
used to tear 
away capsule. 
Large iridectomy 



Lens and capsule 
removed to- 
gether 

Usual operati >n 



None 



\ vitreous lost. 
None . . , . . . . 



^ Hosted by GOOgle 



1893-1889] 



RESULTS OF CATARACT EXTRACTION. 



119 



Secondary 
complications. 



Immediate 
result. 



Remote 
result. 



Secondary 
operations. 



Complica- 
tions after 
secondary 
operations. 



Result 
after 2nd 
operation. 



Remark.'!. 



None 

Pupil drawn 

right up 
None ........ 

Atropine irrita- 
tion, glau- 
coma, ant. 
synechia 

None 

Prolapse of iris 

Iritis 

K. striata 

None 

None 

11 

•>•) •«••••.. 

5J * * 

)J ........ 

Post synechias 



5/60 J. 


18 


6/36 J. 


6 


6/36 J. 


12 


6/36 J. 


16 


6/18 J. 


1 


6/24 J. 


12 


2/60 J.19 


1/60 




5/60 J. 


19 


3/60 J. 


19 



6/9 J. 1 



6/12 J. 1 
6/12 J. 1 

6/24 'J. 15 
3/60 j\ 19 



Division of 
ant. syne- 
chia (3) 



Iridectomy 
for pro- 
lapse 

Needling 



Needling 



Outer limb 
of iris 
entangled 



6/]2 J. 1 



6/12 J. 1 



6/18 J. 8 



6/36 J. 15 



Delirium tremens. 

Choroidal atrophy. 
R., No. 1275. 

Capsule. 



L., No. ~936 (year 
1891). 

L. extracted else- 
where. 

R., absolute glau- 
coma. 



1/60 J. 18 



6/36 J. 14 
J. 18 



2/60 

J. 16 

3/60 J. 18 



6/6 J. 1 

6/24 



6/6 J. 1 



Vitreous opacities. 



Hosted by GOOgle 



120 



ON THE IMMEDIATE AND REMOTE 



[1889 



•—i CD 



Eye 



Age. Sex. 



Condition 
of eye. 



Condition 
of patient. 



! 



Operation. 



Complications 

at time 
of operation. 



10 

11 
12 
13 



14 

15 
10 

17 

18 

19 
20 
21 



22 
23 

24 
25 

26 

27 

28 
29 

30 

31 

32 
33 



185 

225 
226 
242 

244 
279 
291 



311 

629 
634 

742 
763 

818 

844 

875 



905 
906 

1002 
1007 

1040 

1071 

1105 
1199 

1249 

1292 

1674 
1685 



57 
70 
70 
44 


F. 
M. 
M. 
F. 


R. 
R. 
L. 
L. 


51 
49 
52 


M. 
M. 
M. 


L. 
R 
R. 


54 


F. 


R. 


61 
66 


F. 
M. 


R. 
R, 


64 


F. 
F. 


L. 
R. 


72 


M. 


L. 


65 


M. 


L. 


64 


F. 


R. 


62 


M. 


L. 


68 


M. 


R. 


63 


M. 


R. 


71 


M. 


L. 


60 


F. 


L. 


58 


F. 


R. 


74 
72 


M. 
F. 


R. 
R. 


63 


M. 


L. 


74 


F. 


R. 


70 


F. 
F. 


R. 
R, 



G-ood 

Choroiditis 

in R. 
Good 

Brown cata- 
ract 
aood 

Incomplete 
cataract 

Brown nu- 
cleus 

aood 

Old ir'.tis. 
Lac. ob- 
struction. 

G-ood 

Corneal 
nebulae 

aood 

Proj ection 

bad 
aood 

Brown cata- 
ract 
Oood 

Hypermalure 
cataract 



aood .... 

Rheumatic 
Oood .... 

5» ... 

Oouty . . . 
aood .... 



Usual operation , 



None 

>? • * 

-^ fluid vitreous 
lost 

Bleeding into 

A.C. 
None 

>5 

,, ......... 

Lens matter re- 
mained 

None 



Some lens mat- 
ter remains 

Lens sticky, 
some soft mat- 
ter remains 

Soft matter re- 
mains 

None 



into 



Bleeding 
A.C. 

Much soft mat- 
ter left 

None 

Soft matter left 
None 



Hosted by 



Google 



1889] 



RESULTS OF CATARACT EXTRACTION. 



121 



Secondary 
complications. 



Immediate 
result. 



E emote 
result. 



Secondary 
operations. 



Complica- 
tions after 
secondary 
operations. 



Result 
after 2nd 
operation. 



Remarks. 



None 

)> 

J, ....... 

Kerato- iritis . . 

Iritis and post 
syn. 

None 

Slight iritis . . 

None 

Iritis and de- 
tached retina 
None 

Iritis followed 

a blow- 
Slight iritis ♦ . 

None 

Iritis 

None 

)> 

Slight iritis . . . 

Iritis and post 

syn. 
None 



3/60 J. 16 
J. 18 
6/18 J. 6 
6/60 J. 16 

J. 20 

6/24 J. 6 
6/36 J. 14 



J. 16 

6/36 J. 18 
1/60 J. 20 

6/60 

6/60 
5/60 J. 15 



6/60 

6/60 
2/60 J. 20 

6/63 J. 16 
6/24 J. 12 



0/60 J. 16 
6/60 J. 10 



6/12 J. 1 
6/6 J. 1 

6/18 J. 8 

6/36 

Hand- 
movement 

6/9 J. 1 

6/6 J. 1 
6/18 J. 16 

6/6 J. 1 

6/Q J. 1 

6/12 



6/12 
6/24 J. 12 

6/12 J. 8 
6/18 J. 1 
6/6 J. 1 

6/18 

6/24 



Needling 



1. Curette 
evacuation, 

2. excision 
in 6 months 



Needling . 



None 



Not noted 



6/6 J. 1 



Vitreous opacities. 



Vitreous opacities. 
No details of fun 
dus seen. 



Yitreous opacities. 



2nd eye. First did 
well. 



2nd eye. 



1st did well. 

1st did well, 
1st did well. 



1st did well. 
Vitreous opacities. 



Hosted by 



Google 



122 



ON THE IMMEDIATE AND REMOTE 



[1889-1890 



?H 










It £ 








R 




Eve. 


Age. 


Sex. 


or 










L. 


— ( 











Condition 
of eye. 



Condition 
of patient. 



Operation. 



Complications 

at time 
of operation. 



34 


1819 


1 


55 


M. 


L. 


35 


2011 


1 


63 


M. 


L. 


36 


2028 


1 


66 


F. 


L. 


37 


2135 


2 


67 


M. 


R. 


38 


2147 


1 


70 


F 


R. 


39 


2191 


1 


70 


F. 


R. 


40 


2233 


2 


72 


F. 


L. 


41 


2236 


2 


69 


M. 


R. 


42 


2198 


2 


72 


M. 


L. 


43 


2280 


2 


64 


F. 


R. 


44 


553 


1 


64 


F. 


R. 



Good , 



Incomplete 

cataract 
Good 



Good . . . . 
,, . . . . 

Very deaf 
Good 



Usual operation . 



None 



9 
10 
11 
12 
13 



14 



175 



312 



375 



516 
522 
599 
56 J 

577 
578 
593 
617 
685 



784 



74 


F. 


L. 


54 


F. 


R. 


67 


F. 


L. 


66 


F. 


L. 


70 


M. 


L. 


53 


F. 


L. 


69 


F. 


L. 


36 


M. 


L. 


64 


F. 


L. 


60 


F. 


R. 


64 


M. 


L. 


74 


F. 


R. 


14 


M. 


R. 


56 


F. 


L. 



Blepharitis, 
&c , myo- 
pia, and 
fundus 
changes 

Old iritis 
and P.S. 
Coloboma 
upwards 

Eye watery 



P. inaction, 

Good 

,, • * . . 

)> 

,, . . . . 

Myopic . . 

Congenital 

catara-t 

Good .... 



Cough [Cylindrical corneal 

; section. Very 

I large iridec- 

j to my ; capsule 

j removed with 

I capsule forceps 

Not noted . . ' „ „ 



Good, 



Paralysis of 
both 3rd 
nerves 

Good 



Forceps extractioi 
of lens and cap- 
sule. 
Usual operation 



None 



Vitreous bulged, 
but did not es- 
cape 

None 



Some vitreous lost 



Hosted by GOOgle 



1889-1890] 



RESULTS OF CATARACT EXTRACTION. 



123 













Complica- 








Secondary 


Immediate 


Remote 


Secondary 


tions after 


after 2nd 


Remarks . 




complications. 


result. 


result. 


operations. 


secondary 
operations. 


operation. 






None 


J. 14 


6/9 J. 1 












Slight iritis 


6/36 J. 12 














and P.S. 
















None 


6/24 J. 14 














Some iritis . . . 


6/60 J. 15 




.. 






1st did well. 




Iritis and P.S. 


5/60 J. 15 


6/9 J". 1 












Slight iritis . . . 


6/24 J. 16 


6 9 J. 1 












None 


3/60 J. 20 
2/60 
5/60 J. 15 


6j6 J. 1 
6/18 J. 6 


* • 






1st did well. 
1 st did well. 
1st did well. 




Slight iritis . . „ 


6/60 J. 18 


6/12 J. 1 








1st did well. 




K.P., vitreous 


6/18 J. 8 


1/60 J. 19 








Last Y. taken in 




opacities 












1893. 2nd eye sup- 
purated No. 875. 





None 


3/60 


6/24 J. 1 








Myopic changes. 




>> 


Hand- 
movement 


6/60 


•• 


•• 




Capsule and vitre- 
ous opacities. 




None 


6/9 


•• 


•• 






R. did well. 




Primary sup 


puration 


•• 


•• 




•• 


Pt. is imbecile. 
Eye finally shr uk. 




Hypopyon, &c. 
None 

Atropine irri- 
tation 
None 

5) ' ' 

55 


6/60 
6/36 
4/60 

6/12 

6/12 
4/60 

6/24 


616 J. 1 
6/9 J". 1 
6/9 J. 1 

6/36 

6/6 J. 1 
6/12 J. 1 


Needling 




6/9 J. 1 


Myopia L. No. 175. 
Anaesthetic — ether. 




Slight iritis . . . 


6/18 J. 6 


6/21 


•♦ 


•• 


•• 


Capsule. 



Hosted by GoOgle 



124 



ON THE IMMEDIATE AND REMOTE 



[1890 



CO CD 



15 
16 



17 

18 

19 

20 
. 21 

22 

23 

24 
25 
26 

27 
28 
29 

30 



31 

32 

33 
34 
35 
36 

37 

38 

39 
40 
41 



820 
821 



822 



920 

943 
961 
962 

678 
1084 
1101 
1116 
1118 
1119 
1148 



1175 

1235 
1314 

1431 

1470 

1507 

1564 

1568 
1569 

1607 
1610 
1626 



Eye. 



A.ge. 



Sex. 



1 


49 


M. 


R 


1 


49 


M. 


E. 


1 


71 


M. 


. R. 


1 


65 


F. 


L. 


1 


52 


M. 


L. 


1 


61 


M. 


L. 


1 


76 


M. 


R. 


1 


57 


M. 


R. 


1 




M. 


R. 


2 


64 


M. 


R. 


1 


68 


F. 


R. 


1 


67 


F. 


L: 


1 


69 


F. 


R. 


1 


54 


M. 


L. 


2 


63 


M. 


R. 


1 


58 


M. 


R. 


1 


70 


M. 


R. 


1 


52 


M. 


"R. 


1 


51 


M. 


R. 


1 


64 


F. 


L. 


1 


43 


F. 


R. 


2 


60 


F. 


L. 


2 


56 


F. 


R. 


2 


68 


F. 


L. 


1 


46 


M. 


R. 


1 


55 


F. 


L. 


1 


55 


M. 


L. 



Condition 
of eye. 



Condition 
of patient. 



Good 

Ch. conjunc- 
tivitis 

Brown cata- 
ract 
Good 

,, ...... 

Ch. conjunc- 
tivitis 
Good 

jj 

>> 

Conjuncti- 
vitis 

Myopia, tre- 
mulous iris. 
C. nebulous 

Good 

j, ...... 

Glaucoma- 
tous 
Good 

Old iritis and 
coloboma 

Good 



Good 

Rh. arthritis 



Not noted , 



Good . . 

33 • • 

3) • * 

33 ' * 

3' " ' 

33 

33 

)l • • 

33 . * * 

33 * * 

33 * ♦ 

33 • • 

Diabetic 
Good . . 



Operation. 



Usual operation . 
Small conjuctiva] 
flap 

Usual operation . 



No iridectomy . . 

Scoop extraction 
Usual operation . 



Complications 

at time 
of operation. 



None 

Lens displaced 
down and out 
with forceps 

Some vitreous 
lost 

Whole lens dis- 
placed by cap- 
sule forceps 

None 

33 • * ' * 

'3 

33 • * • 

Difficulty in ex- 
tracting lens. 
Some vitreous 
lost 

None 

33 

Vitreous lost . . . 
None 

33 

None 

Soft matter re- 
mained 
None 



Hosted by GOOgle 



1890] 



RESULTS OF CATARACT EXTRACTION. 



125" 





Secondary 
complications. 


Immediate 
result. 


Remote 
result. 


Secondary 
operations. 


Complica- 
tions after 
secondary 
operations. 


Result 
after 2nd 
operation. 


Remarks. 




Slight iritis . . . 
None 


6/6 J. 4 

6/36 


6/9 J. 1 
6/12 J. 1 






■• 


L. lost from injury. 




Opacity of 0.. 


6/36 














Iritis and K. 
striata 


6/18 J. 10 


•• 






•• 


Total post synechias 
inR. 




None 

>) - • • 

Iritis and P. 3. 


2/60 
6/60 ' 


616 J. 1 
6/12 J. 1 




;: 




R. blind from in- 
jury. 

6/12 J/1 in 1895. 




?5 )) 

Slight iritis . . . 
K. striata 


5/60 J/18 
6/12 

6/36* 


6/9 J. 1 
6/9 
6/9 J. 1 


•• 






L. did well. 




None 

Eye shrinking 
Primary sup 


6/60 
6/24 J. 6 

No P.L. 
puration 


•• 




•- 




L. old iritis after 
extraction. Did 
badly. 

L. excised for pre- 
vious - inflamma- 
tion. 




None 

Prolapse of iris 

None 

K. striata 

None 


6/18 

Hand 
6/18 
6/60 


1/60 J. 19 

movement 
6/18 J. 1 


1. Needling 

2. Capsule 
extraction 
Iridectomy 

for pro- 
lapse 


None 


6/9 J. 2 
6/12 J. 1 


Detached retina. 

Vitreous opacities. 
Capsule present. 

Corneal opacity. 
Coloboma down and 




None 

)> 


6/60 ' 
6/18 


6/9 J. 1 








Detached retina in 

R. 
L. did well. No. 784. 
R». did well. 

lS T o. 1101. 




Slight iritis . . . 


6/18 J. 1 













Hosted by GOOgle 



126 



ON THE IMMEDIATE AND REMOTE 



42 



43 
44 

45 

46 

47 



48 



[1890-1891 



P-TSjo 



1638 



1679 
1698 

1742 

1754 
1809 



1830 



^J.e. 



Atfe. 



Sex. 



Condition 
of eye. 



Condition 
of patient. 



1 


71 


F. 


R. 


1 


66 


P. 


R. 


1 


63 


M. 


L. 


1 


66 


M. 


L. 


1 


64 


M. 


R. 


2 


76 


M. 


L. 


2 


53 


M. 


L. 



Good . . 



Corneal ne- 
bulae 
Good 

Good 



Good, 



Diabetes. 
Yery bad 
health 



Operation. 



Complications 

at time 
of operation. 



Usual operation . 



None 



Lens did not 
come readily 



Pt. yery un- 
steady 



6 

7 

8 

9 

10 



11 
12 



13 
14 



60 


1 


61 


M. 


L. 


155 


1 




M. 


R. 


214 


1 


52 


M. 


L. 


2S4 


1 


60 


F. 


L. 


367 


2 


64 


F. 


L. 


510 


1 


57 


F. 


L. 


608 


1 


65 


M. 


L, 


647 


1 


58 


M. 


L. 


651 


1 


hO 


F. 


R. 


694 


2 


67 


F. 


R. 


724 


2 


66 


M. 


R. 


743 


2 




.. 


.. 


744 


2 


65 


F. 


R. 


850 


2 


70 


M. 


L. 



Eypermature 
cataract 



Good 

Brown cata- 
ract 



Good, 



Pupil inac- 
tive. Myo- 
pia 



Good. 



Divergent 

eye 
Good 



Not very 
good. Albu- 
minuria 



Good , 



Paralysis of 
3rd nerve 



Good 



Cylindrical cor- 
neal section. 
Very large iri- 
dectomy. Cap- 
sule ; removed 
with forceps 

Usual operation . 



None 

» 

Much bleediiij 
None 



Hosted by 



Google 



1890-1891] 



RESULTS OF CATARACT EXTRACTION. 



127 



Secondary 
complications. 



Immediate 
result. 



Remote 
results. 



Secondary 
operations. 



Complica- 
tions after 
secondary 
operation. 



Result 
after 2nd 
ope ration. 



None 

Some iritis. . . . 
None 

jj •******' 

Some iritis. . . . 
Prolapse of vi- 
treous 

None 



6/12 J. 1 



6/12 J. 1 
6/60'J. 12 

6/18 J. 4 

6/36 J. 10 
6/36 J. 6 



6/60 



6/24 

6/9 J. 1 

6/6 J. 1 
6/60 J. 14 



Needling 



None . 



6/60 



Remarks. 



Thrombosis of cen- 
tral artery of re- 
tina. 



R. did well. No. 961. 
Pupil drawn up. 
Eccentric vision. 

R. extracted else- 
where ; did well. 





None 


6/12 


6/6 J. 1 












AfewP.S 


6/24 


6/60 J. 12 
6/6 J. 1 








Fine changes at 
rnar.ula and at 
periphery. 




K. striata .... 


6/60 














,, . . . . . 


6/24 


6/18 






•• 


R. did not do very 
well. 




None 

3) ' * * 


6/18 J. 6 
6/24 

6/6 J. 1 
6/36 
6/60 J. 14 

6/12 J. 1 
6/18 J. 10 


6/6 J. 1 
6/6 J. 1 

6/9 J. 1 


•• 




•• 


Old choroiditis. 

L. suppurated. No. 
375 (year 1890). 
Globe now shrunk- 
en. Old choroiditis. 

L. did well. No. 
1742 (year 1890). 




Iritis and P.S. 


6/12 




, , 






1st eye did well. 




None 


6/9 






. 




1st eve did well. No, 
1235 (year 1890). 



Hosted by 



Google 



128 



ON THE IMMEDIATE AND REMOTE 



[1891 



f- 










.— i CD 
<3 -*- 








R. 


"cL'bJO 


%e. 


Age 


Sex. 


to 


QO O 








L 













Condition 
of eje. 



15 


866 


1 


69 


M. 


R. 


16 
17 


886 
916 


2 
1 


58 
76 


M. 

F. 


R. 
R. 


18 


1138 


1 


71 


F. 


R. 


19 
20 


1333 
1351 


2 
2 


76 
65 


F. 
F. 


R. 
R, 


21 


1395 


1 


50 


M. 


R. 


22 


1400 


1 


67 


F. 


L. 


23 


1408 


1 


73 


F. 


R. 


24 


1435 


1 


69 


F. 


R. 


25 
26 

27 
28 
29 


1505 
1508 
1510 
1515 
1528 


1 
1 
1 
1 
1 


70 
70 
66 
62 
64 


F. 
M. 
M. 
F. 
M. 


R. 
R. 
R. 
R. 
R. 


30 


1552 


2 


53 


M. 


L. 


31 


1555 


1 


70 


F. 


L. 


32 
33 
34 


1637 
1685 
1786 


1 
1 
1 


72 
56 
60 


M. 
M. 
F. 


L. 
R. 
R. 


35 
36 


1847 

1875 


2 
1 


64 
37 


F. 
F. 


R. 
R. 



G-ood 

J, . . . . . 

5> 

j) . . . . . 

Ch. conjunc 

tivitis 
Incomplete 

cataract 
Mvopic . . . 
aood 



Old iritis, 
and colobo- 
ma down 
and in, 
movable 
lens 

Good 



Condition 
of patient. 



Operation. 



Good 

>> 

jj . . . . . 

5) .... 

Neurotic . . 
aood 

>} 

Dyspeptic . 

Deaf 

aood 

Heart disease 
Good .... 



Usual operation 



Conjunctival flap. 
Cystotome used 
to open capsule 

Usual operation . 



Complications 

at time 
of operation. 



Section down 
and in. Scoop 
extraction 



Usual operation . 



None 

a 

Soft matter left 

None 



Fluid vitreous 
lost 



Soft matter left 



None , 



Hosted by GOOgle 



1891] 



RESULTS OF CATARACT EXTRACTION. 



129 



Secondary 
complications. 



Immediate 
result. 



Remote 
result. 



Secondary 
operations. 



Complica- 
tions after 
secondary 
operations. 



Result 
after 2nd 
operation. 



Remarks. 



Small prolapse 
of vitreous 

Hyphfema .... 

Slight iritis 
and E.. striata 



Hyphsema . . . 
None 

Purulent iritis 

Atropine irri- 
tation 
None ■ 

)> • • 

,, ........ 

5 J ' ' ' 

Keratitis stri- 
ata. Iritis 
and P.S. 

None 

j, ........ 

Slight iritis . . . 

None 

Eye remained 
very red for 
many days 

K. striata. 



6/12 J. 4 

6/9 J. 1 

6/24 



6/24 
6/6 J. 1 

Fingers at 

10" 
6/12 

6/18 

6/36 

6/24 
6/24 
6/12 
6/12 
6/60 

6/12 



Fingers at 

6" 
6/36 
6/18 
6/18 



6/18 
6/60 



J. 1 



ej6 j. i 

Fingers at 

6" 
6/6 J. 1 



6/18 

6/9 
6/9 



Iridotomy 



Vitreous 
lost 



6/18 



6/9 
6/9 



J. 1 
J. 4 



6/24 J. 15 



Needling 



None , 



6/12 J". 8 



L. did well. No. 60. 



L. did well. No. 
1470 (year 1890). 

Myopia. 

L. lost from injury. 



R. extraction. See 
No. 1431 (year 
1890). L. vitre- 
ous opacities. 



Much capsule. 



L. did well. 



Hosted by GOOgle 



130 



ON THE IMMEDIATE AND REMOTE 



[1892 






Eye. 



Age, 



Sex. 



Condition 
of eye. 



Condition 
of patient. 



Operation. 



Complications 

at time 
of operation. 



10 
II 

12 

13 
14 
15 
16 
17 
18 
19 



20 
21 

21 
23 
21 

25 
26 

27 



107 



173 

222 

239 

260 
332 



335 

445 



611 



683 
708 

723 

737 
753 
834 
854 
878 
897 
915 



936 
1012 
1053 
1057 
1460 

1501 

1507 
1522 



2 


70 


F. 


L. 


1 


47 


F. 


L. 


2 


61 


F. 


L. 


2 


63 


M. 


L 


1 


26 


F. 


L. 


1 


64 


F. 


L. 


2 


56 


M. 


L. 


1 


65 


M. 


R. 


2 


72 


F. 


L. 


2 


77 


F. 


L. 


1 


50 


F. 


R. 


1 


65 


M. 


L. 


1 


60 


F. 


L. 


1 


73 


F. 


R. 


1 


60 


F. 


L. 


2 


73 


M. 


R. 


1 


69 


M. 


L. 


1 


66 


F. 


L. 


1 


68 


F. 


R. 


1 


70 


F. 


R. 


1 


52 


F. 


R. 


1 


71 


F. 


R. 


1 


54 


M. 


R. 


1 


60 


M. 


L. 


1 


87 


M. 


R. 


1 


67 


F. 


L. 


1 


65 


F, 


L. 



Myopic . . . . 



Fairly good 
projection 



Good. 



? Traumatic 
Projection 
bad 



Good 



Myopic .... 



Good , 



Slight con- 
junctivitis 
G-ood 



Deaf. . 



Good 

v • • » • 

j> 

>> 

Unsteady . . . 

Rheumatic . 
Good 

Gouty 

Good 

Unsteady . . 

Good 

Fairly good 

Cough 

Cough ...... 

Very feeble. 
Good ...... 

Neurotic. . . 



Cylindrical cor- 
neal section . 
Yery large iri- 
dectomy. Cap- 
sule removed 
with forceps 

Usual operation . 



None , 



Soft matter left 
None 

?) 

jj • 

>) 

jj • • 

j) j * 

3> 

3J • • . « 

Vitreous lost . . . 

None 

None 

Behaved badly, 
vitreous lost 

None 

)> • 

3) 

>> • * 

>> 

'J 

Soft matter left 



Hosted by GOOgle 



1892] 



RESULTS OP CATARACT EXTRACTION. 



131 





Secondary 
complications. 


Tm mediate 
result. 


Remote 
result. 


Secondary 
operations 


Complica- 
tions after 
secondary 
operation. 


Result 
after 2nd 
operation . 


Ren' arks. 




None 

,, ........ 


6/24 

Hand- 
movement 


Fingers at 
6" 








R. did fairly well. 
No. 1505 (year 
1891). 

Optic atrophy. Dis- 
seminated choro- 
iditis. 




Some iritis. . . . 


6/18 






. # 


, , 


R. did well. No. 














1515 (year 1891). 


1 


None 

,, ........ 


6/9 


* • 






* * 


R. did well. No. 18 

(year 1889). 
R. healthy. 


I 


(Cerato-iritis . . 


6/24 J. 1 


2/60 


■ • 






Vitreous opacities. 
Kerato-iritis in 8 
months. 


w 


Slight iritis .. 


6/6 


, . 








R. did well. 


r 


Slight protru- 


6/60 














sion of vitre- 














L 


ous 














► 


N~one 


6/36 


6j6 J. 1 








R. had thrombosis of 
retinal artery. See 
No. 1638 ' (vear 
1890). 




Some iritis. . . . 


6/24 














Sma'l vitreous 


6/24 








, , 


R. did well. No. 




prolapse 












1292 (year 1889) 


-None 


6/36 




.. 


.. 




Capsule chiefly pos- 










terior. 


1 » 


6/12 










K striata 


6/60 












None 


6/18 












! K. striata 


6/24 












None 


6 18 
6/36 J. 14 


6/6 J. 1 










Kerato-iritis in 




6/18 J"; 4 




. # 




L. excised for sym- 




Li. r sympa- 
l hetic, prolapse 
of vitreous 












pathetic ophth.' R. 
remained good. 




Corneal striae . 


6/60 














JS one 


6/12 J. 10 














j) 

>> • • 

,, ........ 

>> 


6/18 J. 6 
6/18 J. 6 
6/12 J. 2 

6/18 J". 6 
6/24 
3/60 J. 19 


6/18 J. 1 
6/12 J. 1 

4/60 J. 14 
6/24 J. 12 








Requires needling. 
Vitreous opacities. 



VOL. XIV. 



Hosted by 



Google 



132 



ON TDE IMMEDIATE AND REMOTE 



[1892-1893 



Eye. 



28 


1536 


1 


29 


1627 


1 


30 


1628 


1 


31 


1735 


2 


32 


1756 


1 


33 


1781 


l\ 


34 


1781 


35 


1793 


1 


36 


1814 


1 


37 


1847 


1 







E. 


Age. 


Sex. 


to 
L. 




M. 


E. 


65 


F. 


L. 


76 


F. 


L. 


65 


F. 


E. 


54 


F. 


L. 


64 


M. 


E. 


66 


M. 


L. 


63 


M. 


E. 


73 


F. 


L. 



Condition 
of eye. 



Dense leuco- 
m a adherens 
Coloboma 
above 
Myopic. 

Over-ripe 

cataract 



Good , 



Post syue- 

ohia 
Corneal ne- 
bula. Myo- 
pia 



Condition 
of patient. 



Operation. 



Grouty 



Albuminuria 
and diabetes 



Diabetes, 
Good 



Diabetic, 
Good . . , 



Spinal cur- 
vature. 
Weak health 



Usual operation 



Scoop extraction 
Usual operation . 



Complications 

ai. time 
of operation. 



None. . . . 



Vitreous 
sented 



prc- 



None , 



Vitreous lust. 
None 



73 



2 99 1 

3 i 101 ! 1 
1 



4 


122 


5 


165 


6 


169 


7 


191 


8 


194 


9 


197 


10 


214 


11 


228 


12 


492 


13 


499 



57 


M. 


E. 


68 


M. 


L. 


77 


F. 


E. 


29 


F. 


E. 


57 


M. 


L. 


38 


F. 


E. 


50 


F. 


E. 


78 


M. 


L. 


60 


M. 


E. 


60 


M. 


E. 


50 


F. 


L. 


65 


F. 


E. 


56 


M. 


E. 



Good - 

,j ...... 

Corneal ne- 
bula. Post. 
synechia 

Ch. conjunc- 
tivitis 

G-ood 



Good 



Diabetes. . 
Alcoholic 



Cylindrical cor 
neal eeclion. 
Very large iri- 
dectomy. Cap- 
sule removed 
■with forceps 

Usual operation . 



None , 



Hosted by GOOgle 



1892-1893] 



RESULTS OP CATARACT EXTRACTION. 



133 



(Secondary 
complications. 



Immediate 
result. 



Remote 
result. 



Secondary 
operations 



Complica- 
tions after 

secondary ,. 

,- - operation, 
operations. L 



Result 
after 2nd 



Remarks. 



K. striata 



Iritis 

None 

Iritis and P.S.. 
None 

Small prolapse 

of vitreous 
K. striata 



1/60 



Fingers at 
12" 

3/60 J. 19 
6/6 J. 1 

6/60 

6/24 
6/24 
6/60 
6/18 J. 8 

6 36 



6/18 J. 6 
616 J. 1 

6/9 J. 1 



L. shrunken globe. 



Vitreous opacities. 



Capsule. 

L. did badly. No. 

332. 
Quite good in 1895. 



Yitreous opacities 

and K. striata. 
Myopic crescent. 





None 

>j • * 


6/12 J. 1 

6/24 J. 12 

J". 19 

6/60 J. 14 


6/18 

6/12 J. 1 
6/6 J. 1 








L. did well. 

Capsule present. 
L. healthy. R. cap- 
sule 

L. did well. No. 
1875 (year 1891). 

Yitreous opacities. 




K. striata 

None 

K. striata 


6/18 J. 10 
6/18 J. 12 

6/18 J. 6 
6/60 J. 16 


6/6 J. 1 

6/12 J. 1 
6/24 J. 8 


•• 


•• 


•• 




None 


6/36 J. 8 














j> • * 

Some iritis. . . . 
None 


6/60 
2/60 J. 16 

4/60 J. 15 
6/24 J. 12 


6/18 J. 6 
1/60 

6/24 J. 12 
6j6 J. 1 


•• 


•• 


•• 


R. did well. No. 651 
(year 1891) cap- 
siile. 

Capsule, &c. 



K 2 



Hosted by GOOgle 



m 



ON THE IMMEDIATE AND REMOTE 



[1893 



P, CD 



Eye. 



Age, 



Sex 



Condition 
of eye. 



Condition 
of patient. 



Operation. 



Complications 

at time 

operation. 



20 
21 

22 

23 
24 
25 

26 

27 

28 

29 



30 

31 
32 
33 



34 

35 
36 



14 


546 


15 


603 


16 


629 


17 


652 


18 


653 


19 


785 



820 
886 

904 

919 
938 
950 

975 
990 

1007 
1013 



1018 

1037 
1053 
1076 



38 
39 



1498 
L501 



1091 2 
1107 ! 1 
1110 I 1 



1395 



68 



60 F. 



R. 



Good 

)> * 

)> 

■)■> ...... 

}> • 

Corneal 
nebulae 
>j 

)> 

Myopic 
Incomplete 

cntaract 
G-ood 

>» 

Cornea nebu 

lous 
G-ood 

>> 

Myopic 
Good 

Myopic 



Good , 



Not good . . . 
Good 



Diabetes, 
unsteady 

Unsteady. . . 

Feeble and 
tremulous 



Alcoholic . . . 
Good 

t> * 

j> 

Diabetic . . 

Good 

Alcoholic . . . 
Good 

,, ...... 

>» 

,, •..».. 

Diabetic and 
asthmatic 

Rheumatic. . 



Usual operation . 



Good 

Rheumatic. 



Scoop extraction. 

Usual operation . 
Scoop extraction. 



Conjunctival flap. 
Small iridec- 
tomy. Capsule 
opened with 
cystotome 

Usual operation . 



None 



Soft matter left 
None 



Vitreous lost. 

Soft matter 

left 
None 



Fluid vitreous 
lost 



None , 



Hosted by GOOgle 



1893] 



RESULTS OF CATARACT EXTRACTION. 



135 



Secondary 
complications. 



Immediate 
result. 



Remote 
result. 



Secondary- 
opera tions. 



Complica- 
tions after 
secondary 
operations. 



' Result 
after 2nd 
operation. 



Remarks. 



Iritis and K. 

striata 

None 

K. striata and 

iritis 
X. striata 



None , 



Secondary pro- 
lapse of vit- 
reous, as re- 
sult of intra- 
ocular haemor- 
rhage 

K. striata 



None 



Some iritis . . . 
•Iritis and P. S. 
K. striata and 
iritis 



None , 



6/60 J. 16 

6/36 J. 14 
3/60 J. 18 

1/60 J. 20 

6/60 J. 14 
1/60 J. 19 



6/60 J. 16 
6/36 J. 6 

6/18 J. 8 

6/24 J. 10 
6/18 J". 8 
6/60 J. 16 

1/60 J. 16 
6/18 J. 12 

6/6 J. 1 



6/18 J. 12 

6/36 J". 15 
6/18 J. 8 
1/60 



6/24 J. 15 
6/24 J. 12 
1/60 J. 19 



6/36 J. 12 



6/12 J. 2 

2/60 J. 18 
6/24 J. 4 

6/6 J. 1 

6/18 J. 2 



6/18 J. 4 



6/9 J. 1 
6/24 J. 6 



6/36 J. 12 
6/9 J. 1 
6/24 J. 12 



6/6 J. 1 
6/9 J. 2 
5/60 J. 10 



6/12 J. 1 



6/2i J. 14 i 6/18 J. 2 
( 6/60 J. 18 ! 6/12 J. 1 



Needling 



Needling 



Excis: 



6/24 J. 11 



None . 



6/6 J. 1 



Optic atrophy. 
Capsule. 



L. blind from an old 
injury. Choroidal 
atrophy and vitre- 
ous opacities. 

Yitreous opacities. 

R, did well. Ex- 
tracted elsewhere. 



Unabsorbed Jens 

matter present. 
Choroidal atrophy. 



Eye shrinking. 



Still some unab- 
sorbed lens matter. 
Yitreous opacities. 

R. did well. No. 652. 

L. lost 40 years be- 
fore. R. yitreous 
opacities. 

R. did well. No. 
1400 (year 1891). 



Hosted by G00gle 



136 



ON THE IMMEDIATE AND REMOTE 



[1893 



u 










^ -2 








K. 




Eye. 


Age. 


Sex. 


to 


m <l> 








Ij 


£& 










m 











Condition 
of eye. 



Condition 
of patient. 



Operation. 



Complications 

at time 
of operation. 



40 

41 



42 
43 



44 
45 
4G 

47 
48 

49 

50 
51 

52 



1521 
1541 



1542 
1561 



1562 

1582 
1640 

1661 
1697 

1698 

1797 
1845 

1907 



1 


5S 


F. 


L. 


2 


55 


F. 


R. 


2 


67 


M. 


L. 


2 


66 


F. 


R. 


1 


58 


M. 


R. 


1 


46 


F. 


L. 


2 


40 


F. 


L. 


1 


82 


F. 


L. 


1 


32 


F. 


R. 


1 


73 


F. 


R. 


1 


60 


F. 


L. 


\) 


51 


F. 


L. 


1 


48 


M. 


L. 



Good .... 

3 , .... 

,, .... 

,j • • • « 

Hypermature 
cataract 

Good 

>) 

>> 

Black cata- 
ract 
Good 



Good .... 
Diabetic . 

Good .... 

)> • • • • 

,j . * . . 
Feeble . . . 

Good 



Usual operation 



Very little cap- 
sule removed 
Usual operation . 



Conjunctival flap. 
Small iridec- 
tomy. Capsule 
opened with 
cystotome 

Usual operation . 



None . 



very 



Cornea 
flaccid 

Vitreous pre- 
sented, but 
none escaped 

Iris buttonholed, 
and then iri- 
dectomy done 
on each side of 
this 

None 



Vitreous pre- 
sented, but did 
not escape 



Hosted by 



Google 



1893] 



RESULTS OF CATARACT EXTRACTION. 



137 













Complica- 


Result 






Secondary 


Immediate 


Remote 


Secondary 


tions after 


after 2nd. 


Remarks. 




complications. 


result. 


result. 


operations. 


secondary 


operation. 














operations . 






None 


6/12 J. l 














Iritis and atro- 


6/36 J. 15 


6/12 J. 1 


, , 


, , 


. . 


L. did well. No. 




pine irritation 












1756 (year 1892). 




None 


6/36 J. 12 


6/9 J. 1 


•• 




•♦ 


R. No.'l076. Vit- 
reous opacities. 




Much iritis and 


6/12 J. 6 


6/6 J. 1 








L. did well after ex- 




irritation of 












traction some years 




conjunctiva 












previously. Con- 
junctival sac irri- 
gated with Id yd. 
Perchlor. 1—1000. 




Intense irrita- 


6/24 


6/9 J. 1 


, . 


. . 


, . 


Conjunctival sac irri- 




tion and K. 












gated with 11yd. 




striata 












Perchlor. 1—1000. 




Marked K 


6/24 J. 19 


. , 


. , 


■•"'', . 


, , 


Conj unctival sac irri- 




striata 












gated with Hyd. 
Perchlor. 1—2000. 




None ........ 


6/18 J". 15 






• * 


• • 


R. No. 603. 




Muck K. stri- 


1/60 J. 19 














ata 
















None 


6/18 J. 4 














Very slow 


6/60 J. 15 














healing 
















None ........ 


6/18 J". 12 


•• 


•• 




.. 


Vitreous full of 
opacities. 




j, ........ 


3/60 J. 18 


6/24 


* * 


* * 


* * 


R. did well. No. 191. 
L. some capsule 
present. 




Much iritis . . . 


6/18 J. 6 













Hosted by 



Google 



138 



ON THE IMMEDIATE AND REMOTE 



[1889 



K) 
11 
Iz 
13 
]4 
15 



16 

17 

is 
19 

20 



21 



22 
23 



24 






74 
109 
133 



275 



312 
327 



374 



400 



421 
503 
505 
514 
588 
596 



611 
656 

659 
934 

879 
937 



1001 
109G 

1109 



25 l 1189 



Eye. 



Age. 



66 


M. 


65 
43 
47 


M. 

F. 

F. 




F. 


69 
47 


F. 


62 


M. 


72 


F. 


61 

60 
63 

48 
44 
72 


F. 

F. 
M. 
M. 
F. 
M. 


38 
55 


F. 


76 
50 


F. 
F. 


83 


M. 


70 


M. 


69 
76 


M. 
F. 


72 


F. 


49 


F. 



R, 



Condition 
of eye. 



Condition 
of patient. 



Good 

Cornea, nebu 
lous. Post, 
synechias 

Projection 
bad 

Good 

Cornea nebu 
lous, old 
iritis, &c. 

Lagophthal* 

mos. Myopia. 

Puncta ob 

] iterated 

Old iritis and 
post syne- 
chias 

Good 

n . . ... 

n 

>) 

Black cata- 
ract 

Incomplete 
cataract 

Post polar 
cataract in- 
complete 

Good 

Brown nu- 
cleus 



Good , 



Very deaf . 
Bad cough. 



Good 



Facial para- 
lysis 

Not noted . . 

Good 



Bad health. 
Good 



Good 



Asthmatic . . 
Good 



Operation. 



Complications 

at time 
of operation. 



Small conjunc- 
tival flap. Iri- 
dectomy. Peri- 
pheral capsul- 
otjmy 



Extraction down- 
wards 

Lids pared and 
united. Usual 
operation for 
extraction 
Whole iris re- 
moved owing to 
patient moving- 
Usual operation 



Lens removed 

with scoop 
Usual operation 



Scoop extraction 
Usual operation 



None 

-£• fluid vitreous 
lost 

None 

)> • 

>i ........ 

5) • • » • 

5) 

i of fluidvitreous 

lost 
None 

)■> 

Loose lens. 
None 



Hosted by GOOgle 



1889] 



RESULTS OF CATARACT EXTRACTION. 



139 



Secondary- 
complications. 



None 

D 

llyphaema. . .. 
j, . . . . 

Slight iritis and 
ulceration of 
C. 

None 

Ant. synechia 

None 

>) 

Iritis 

None 

)) 

Hypopyon 

iritis 
Capsule and 

hypopyon in 

2 months 
None 

>> 

Slight iritis . . . 
None ........ 



Immediate 
result. 



6/24 J. 15 



J. 18 
J. 14 

1/60 



J. 18 
Fingers 
6" 



at 



6/60 J. 16 



6/60 J. 16 



6/24 J. 12 
6/24 J. 12 
6/60 

6/60 J. 18 
6/60 
6/60 



6/24 
6/60 

6/60 

Hand- 

moyement 



Death. 
Pneumonia 



6/60 J. 15 



6/24 J. 6 



Remote 
vision. 



Secondary 
operations. 



Complica- 
tions af'ttr 
secondary 
operations. 



Result 
after 2nd 
operation. 



Remarks. 



3/60 J. 19 



6/36 
6/6 J. 1 
1/60 J. 16 



6/?4 



6/18 J. 4 



2/60 J. 18 
6/12 J. 1 
6/18 J. 1 
6/9 J. 1 
6/12 J. 1 
6/12 J. 1 



6/9 

6/18 
P. L. 



Needling 



Needling 



Needling 



Hand- 
I movement 



None 



6/12 J. 2 



6/6 J. 1 



> J. 1 



R. did well. 



Anaesthetic — ether 
and chloroform. 



R. did well. 

1st eye did not do 

well. Ether and 

chloroform. 



L. did not do well. 



R. did well. 



L. did not do well. 
Hjpopyon and 
glaucoma followed . 



Refused excision. 



R, did well. 
Hetached letina. 



Hosted by GOOgle 



140 



^ 



ON THE IMMEDIATE AND REMOTE 



[1889-1890 






Eye. 



Age. 



Sex, 



Condition 
of eve. 



26 


1215 


2 


55 


M. 


L. 


27 


1234 


1 


76 


F. 


R, 


28 


1256 


1 


56 


F. 


L. 


29 


1289 


2 


SO 


M. 


R. 


30 


1641 


1 


51 


F. 


R. 


31 


1665 


1 


67 


M. 


L. 


32 


1666 


1 


76 


M. 


R. 


33 


1690 


1 


38 


M. 


R. 


3L 


1700 


1 


61 


F. 


R. 


35 


1722 


2 


55 


M. 


L. 


36 


1854 


2 


68 


M. 


R. 


37 


1S81 


1 


74 


F. 


R. 


38 


1915 


1 


36 


F. 


l: 


39 


2093 


2 


51 


F. 


L. 


40 


2121 


1 


66 


F. 


R. 


41 


2134 


1 


57 


M 


L. 


42 


2227 


2 


37 


M. 


R. 


43 


2234 


1 


57 


F. 


R. 



Hypernia- 

t ure 
G-ood 

jj ...... 

Brown nu- 
cleus 

Myopia. 
Deep A. C. 

Extensive 

choroiditis 
Good 

? Secondary 
cataract 

Good 

jj 

Myojna. L. 
alwa^ s de- 
fective 

Projection 

fair 
Good 

Post polar 
opacity. 
Incomplete 
catara ct 



Condition 
of patient. 



Good. 



Operation. 



Complications 

at time 
of operation. 



Usual operation 



None , 




After preliminary 
iridectomy 



Soft matter left 



None . 



Soft matter re- 
mained 
None 



1 


98 


1 


63 


F. 


L. 


2 


238 


2 


49 


M. 


L. 


3 


401 


1 


50 


F. 


R. 


4 


4S7 


1 I 

J 


55 


F. 


L. 



Good . 



Good , 



Conjunctival flap. 
Iridectomy. Pe- 
ripheral section 
of capsule with 
knife 

Usual operation . 



None , 



Rheumatic. . _ „ „ . Soft matter left 

Good ; No conjunctival j None ....... 

I flap 



Hosted by G00gle 



1889-1890] 



RESULTS OF CATARACT EXTRACTION. 



141 



Secondary 
complications. 



Immediate 
result. 



None , 



Suppuration 

iritis 
Pan oph thai - 

ii it is 



Serous cyclitis 
and X. P. 



Suppuration . . 
None 

55 ........ 

Suppu 

None ..--.... 
Slight iritis . . . 

None 

Some iritis. . . . 
Slight iritis . . . 
Iritis and glau- 
coma 



1/60 

Hand- 
moyement 



Fingers at 

12" 
6/60 J- 12 



4/60 J. 14 



6/36 J. 12 
3/60 J. 16 
ration 

6/60 J. 12 
5/60 J. 15 



5/60 J. 15 

6/36 J. 15 
6/60 J. 2 
6/24 J. 12 



Eemote 
result. 



Secondary 
operations. 



Complica- 
tions after 
secondary 
operations. 



Result 
after 2nd 
operation. 



Remarks. 



6/36 J. 10 



Hand- 
movement 
6/60 J. 15 



6/18 J. 4 

6/60 
6/9 J. 1 
6/36 J". 8 
P. L. 



P. L. 



6/36 J. 12 
6/6 J. 1 
6/18 J. 4 



Iridectomy 
Excision. . 



Iridectomy, 
Iridotomv 



Excision 



Needling, 

Iridectomy 

Excision 



N eedling 

Sclerotomy 
Iridectomy 



Iritis 



Finger 
12" 



s at 



Fingers at 



6/12 J. 12 

6/18 J. 1 



6/9 J. 1 
P*. L. 



E. lost vitreous (No. 
656). 



Primary suppura- 
tion. 

Optic atrophy. Ti- 
to eous opacities. 

Sympathetic ophili. 
caused by the L. 
See No. 2093. 



Pr imary s n p p u r a - 

tion. 
L. healthy. 

1st did well. 
Wrinkled capsule. 
T-3. 



Excised after K. P., 
&c.> in both pro- 
bably sym path e lie. 
See 1641. 



Capsule. 
1st did well. 
Eye shrinking 



Serous iritis 
and keratitis 


3/60 


Hand- 
movement 


•• 


•• 




Serous iritis in seven 
months. 


punctata 














None . k 


6/24 J. 12 
6/12 


616 J> 1 

6/12 
6/9 J. 1 


Needling . 


Iriiis . . . 


Not noted. 


K did well (No. 514, 
1889). 



Hosted by 



Google 



142 



ON THE IMMEDIATE AND REMOTE 



[1890-1891 



ki 



6 

7 

8 

9 

10 

11 

12 

13 

14 



15 

16 

17 

18 
19 

20 
21 



•15 % 



\& 



Eye 



531 

573 

722 

772 
817 
886 
934 
1103 

1027 

1131 



1506 

1510 

1585 

1683 
1761 

1895 
1896 



Condition 
of eye. 



Condition 
of patient. 



65 


F. 


L. 


69 
66 


M. 
M 


L. 
L. 


75 
49 
60 
49 

70 


M. 
F. 
F. 
F. 
M. 


L. 
R. 
R. 

L. 
R. 


61 


M. 


R. 


63 


M. 


L. 


36 


F. 


R. 


65 


M. 


R. 


59 


F. 


L. 


60 
67 


M. 
M. 


R. 
R. 


75 


M. 


R. 


58 


b\ 


L. 



Good 



Morgagnian 

cataract 
Good 



Incomplete 

cataract 
Good 



Good . 



Xot good 
Good . . . 



Not good 
Good .... 



Unsteady 



Good . 



Operation. 



Usual operation . 



After prelimi- 
nary iridectomy 
Usual operation 

After prelimi- 
nary iridectomy 



Usual operation . 



Capsule lacerai ed 
with needle 
before making 
section 

Usual operation . 



Complications 

at time 
of operation. 



None 



Soft matter left 



None , 



Great difficulty 
in delivering 
lens 

Lens loose .... 



None , 



1 


156 


1 


54 


M. 


R 


2 




2 


54 


M 


L. 


3 


183 


1 


39 


M. 


R. 


4 


211 


1 


55 


F. 


R. ! 


5 


212 


1 


54 


F 


R . 



R Good Good 



Diabetes . . 

Good 

Very bad 
health. 
Melancho- 
lic, &c. 



Small conjuncti- 
val flap. Iridec- 
tomy. Usually 
peripheral sec- 
tion of capsule 



None 



Hosted by GOOgle 



1890-1891] 



RESULTS OF CATARACT EXTRACTION. 



143 



Secondary 
complication. 



Immediate 
result. 



(Edema of con- 
junctiva 

Sone 

>» ........ 

j> 

>> 

Irritation of 

lids 
iSFone 

Some iritis and 
P.S. 

Slight iritis . . 



Suppurative 
iritis 



Iritis 



I 



6/(5 J. 1 

6/36 
6/60 

6/36 
6 18 
6/6 J. 1 
6/12 J. 1 



6/24 J. 12 
2/60 

6/36 

6/60 

6/24 

6/24 J. 6 
Hand- 
movement 



3/60 



6/24 



Remote 
result. 



Secondary 
operations 



Complica- 
tions after 
secondary 
•perations. 



Result 
after 2nd 
operation. 



6/6 J. 1 

0/6 J. 1 
6/60 



6/6 J. 1 

6/9 J. 1 
6/24 J. 1 

6/12 J. 1 

6/6 J. 1 

6/12 J. 1 
Fingers at 
10" 

6/12 J. 2 
6/6 J. 1 



Needling . 



Needling 



Needling . 
Needling . 



Suppura- 
tion 



Grlaucoma 
and hy- 
popyon 



P.L. 



6/24 J. 2 



fi/5 J. 1 

Fingers 

barely. 



Remarks. 



R. did well. 

R. did well. 
L\-2. 



L. did well. 



R. had K. punctata 
after extraction. 
In L. there were 
vitreous opacities, 
&c. 

R. cornea nebulons, 
&c. 



L. did well. 



None . 



Corneal ulcer, 
iritis, and P.S 



6/60 



6/36 
6/9 
6/60 
6/36 



6/60 



6/60 
6/36 
6/24 J. 10 



Needling 



Needling 
Needling 
Needling 



None 



6/24 



6/24 
6/24 
6/12 J. 



Tobacco amblyopia. 



Hosted by GOOgle 



144 



ON THE IMMEDIATE AND REMOTE 



[1891 



c§ is! 
1^ 


Eye. 


Age. 


Sex. 


R, 
or 
L. 



Condition 
of eye. 



9 
10 

11 

12 

13 
34 
15 

16 

17 

18 
19 

20 



21 

22 

23 
21 
25 



26 
27 

28 

29 
30 

31 



Condition 
of patient. 



Operation. 



262 
2S6 


1 
2 


69 
67 


F. 


R. 
R. 


301 


1 


67 


M. 


R. 


509 
511 


2 

2 


55 
61 


F. 

M. 


L. 

L. 


532 


2 


56 


F. 


R. 


846 


2 


55 


M. 


L. 


915 


2 


75 


F. 


L. 


943 


1 


78 


F. 


L. 


968 


1 


€55 


M. 


L. 


982 


2 


72 


F. 


R, 


1313 


1 


49 


F. 


L. 


1327 
1380 
1411 


1 
1 

2 


75 
64 
50 


F. 
M. 
IVI. 


L. 
L. 
L. 


1456 
1458 


1 

1 


51 

72 


F. 
M. 


L. 
R, 


1571 
1578 
1S13 


1 

1 
1 


70 

72 
60 


M. 
F. 
F. 


R 
R. 
L. 


1636 
1697 
1702 


1 

2 
1 


68 
79 
62 


M. 
F. 

M. 


R. 
R. 
R. 


1719 
1737 


1 
1 


78 

72 


M. 
M. 


L. 
R, 


1743 


1 


75 


F. 


R. 



Good 

jj 

Projection 
not accurate 
Good 

Black catar- 
act- 
Good 

Black catar- 
act 

Good 

Loose Lens 

Good 

,, ...... 

Epiphora . 

Good. 

Myopic. . . . 

Good 

Myopic .... 
Good 



Good 

?> 

,, ...... 

>> 

Ch. bronchi- 
tis 

Diabetes . . 

Good 

Asthmatic 
anddyspep 
tic 

Alcoholic . . 

Good 

Ch. bron- 
chitis 

Good 



Usual operation. 



Complications 

at time 
of operation. 



None 



Lens difficult to 
extract 



None 



Hosted by GO Ogle 



1891] 



RESULTS OF CATARACT EXTRACTION. 



145 













Complica- 


Result 






Secondary 


Immediate 


Remote 


Secondary 


tions after 


after 2nd 


Remarks. 




complications. 


res ait. 


result. 


operations 


secondary 
operations. 


operation. 






Iviii.s, &lc 


6/18 


. 6/6 J. 1 












None 


6/60 


3/60 J. 19 








L. did well after 
extraction six 
years ago. Dense 
capsule in R. 




Iritis 


6/24 - 


6/18 J. 4 


•• 






Vitreous opacities. 




K. striata .... 


6/60 


6/6 J. 1 


t # 




.. 


R. No. 211. 




None 

>> 


6/18 J. 1 
6/24 


•• 


•• 


•- 


•• 


R. No. 1027 (year 

1890). 
L. No. 487 (year 

1890). 






616 J. 1 


6/18 J. 8 


Needling. 
Division 
of mem- 
brane with 
keratome 




6/18 J. 12 
1/60 


R. did well after 
extraction four 
years ago. 

Eye not quiet when 
V. was taken. 




» 


6/24 


•• 




•• 


•• 


R. No. 1109 (year 
18S9). 




•> 


6/36 


6/12 












Iritis and P.S. 


6/24 


6/60 J. 15 








R. lost after catar- 
act extraction else- 
where. L. wants 
needling. 




None 

>> 


6/36 
6/60 


6/60 J. 15 








L. did well after 
extraction three 
years ago. R. cap- 
sule present. 




Iritis and P.S. 


6/12 














None 


1/60 


6/12 J. 10 








Vitreous opacities. 




Hyphamia . . . 


6/12 


• • 








L. did well after ex- 
traction five years 




None 


6/24 


6/18 


Needling 




6/6 J. 1 


ago. 




„ ........ 


6/12 














Iritis 


6/60 














None 


6/36 


1/60 J. 20 


Needling 




6/24 J. 2 


Fundus changes. 




>> 

5) 


6/60 

6/18* 
1/60 

6/60 


6/6 J. 1 
4/60 


Needling 


•• 


6/18 J. 2 


L. No. 943. 
Capsule. 




" 


6/36 


6/36 J. 15 


.. 


•• 


•• 


Capsule and lens 
matter. 




)} 


6/24 


6/18 J. 8 











Hosted by GOOgle 



146 



ON THE IMMEDIATE AND REMOTE 



[1891—1892 













,— ( © 








R. 




Eye. 


Age. 


Sex. 


to 










L. 


W 











Condition 
of eye. 



Condition 
of patient. 



Operation. 



Complications 

at time 
of operation. 



32 


1807 


1 


81 


M. 


R. 


33 


1819 


2 


69 


F. 


L. 


34 


1873 


1 


60 


M. 


L. 


35 


j? 


2 


jj 


M. 


R. 



Fairly good Usual operation . None 



Unsteady 
Good .... 



Vitreous lost 
None 



1 


38 


1 


49 


F. 


R. 


2 


190 


1 


64 


M. 


L. 


3 


208 


1 


71 


M. 


L. 


4 


220 


1 


58 


M. 


L. 


5 


240 


1 


78 


M. 


L. 


6 


262 


2 


51 


F. 


R. 


7 


273 


1 


55 


F. 


L. 


8 


291 


1 


82 


M. 


R. 


9 


311 


2 


49 


F. 


L. 


10 


511 


1 


60 


F. 


R. 


11 


644 


2 


75 


F. 


L. 


12 


645 


2 


78 


M. 


R. 


13 


705 


1 


74 


F. 


R. 


14 


709 


1 


73 


F. 


R. 


15 


835 


1 


60 


F. 


R. 


16 


914 


2 


68 


F. 


L. 


17 


978 


1 


58' 


F. 


L. 


18 


992 


1 


76 


M. 


L. 


19 


1090 


1 


71 


F. 


R. 


20 


1097 


2 


58 


M. 


R. 


21 


1445 


1 


64 


F. 


R. 



Good , 



Epiphora. . 



Good , 



Epiphora. 
Good 



Brown cata- 
ract 



Good , 



Projection 

fairly good 
Good' 



Jood , 



A]buminuria 
diabetes. 
Parahsisof 
R. arm 

Good .... 



Deaf . , 
Good . 



Diabetes and 
gout 



Conjunctival flap. 
Iridectomy. 
Usually peri- 
pheral section 
of capsule 

Usual operation . 



None , 



Soft matter left 
None . 



Vitreous lost. 
None 



Hosted by GOOgle 



1891-1892] 



RESULTS OF CATARACT EXTRACTION. 



147 





Secondary 
complications. 


Immediate 
result. 


Remote 
result. 


Secondary 
operations. 


Complica- 
tions after 
secondary 
operations. 


Result 
after 2nd 
operation. 


i 

Remarks. 




Severe iritis one 
month after 
leaving Hosp. 

N one 

j> 
Atropine irri- 
tation 


4/60 

6/24 

6/24 J. 6 
6/24 J. 6 


P. L. 

6/12 J. 2 

6/12 J. 2 
6/12 J. 2 


Iridotomy 


Vitreous 
lost, hy- 
popyon 


P. L. 


R. No. 262. 



None .... 

Iritis 

None 

Hyphfenia . . 
None 

Hyplieema . . 
Atropine irri 
tation 

None 

>> 

Entropion . . , 
"VOL. X1Y. 



6/6 J.'l 



6/12 
6/24 J. 6 



6/6 



6/36 

6/18 

6/6 J. 1 
6/18 
6/3 



6/24 J. 12 

6/12 
3/60 



6/36 



1/60 



6/36 

6/18 
6/24 J. 4 



6,9 J. 1 

3/60 
6/6 J. 1 



3/60 



6/6 J. 1 

3/60 
1/C0 



6/6 J. 1 



J. 12 



2/60 J. 19 
6/9 J. 1 



JNeedlinc 



Needling 



Needling 



Needlii 



6/6 J. 1 
6/6 J. 1 



6/9 J". 1 



6/6 J. 1 
6/6 J. 1 



6/18 J. 1 



R. shrunken globe 
after accident. 

V. = 3/60 before 

needling. 
L., No. 934 (year 

1890). 



R. did well. 

R., No. 1743 (year 

1891) 
L., No. 240. 



Extensive fundus 
changes. 



R., cataract ex- 
tracted eight years 
ago, did not do 
very well. 

Vitreous opacities. 

Dense capsule. 

L., No. 220. 
R., No. 301 (year 
1891). 



Hosted by G00gle 



148 



ON THE IMMEDIATE AND REMOTE 



[1892-1893 



O 



22 
23 
24 

25 
26 

27 

23 
29 

30 



*Ph"Sd 

CO <£> 


Eye. 


Age. 


Sex. 


R. 

or 
L. 


1464 


2 


68 


M. 


L. 


1481 


1 


57 


F . 


L. 


1621 


1 


58 


F. 


R. 


1697 


1 


68 


F. 


L. 


1736 


1 


63 


F. 


R. 


1825 


1 


68 


F. 


R. 


1826 


1 


34 


F. 


L. 


1833 


1 


76 


M. 


R. 


1816 


1 


72 


F. 


R. 



Condition 
of eye. 



Projection 

fair 
Good 

Corneal ne- 
bulse 

Brown cata- 
ract 
Good 

>» 

jj 

Lagophthal- 
mos 

Has had lac. 
abscesses in 
both. 



Condition 
of patient. 



Operation. 



Complications 

at time 
of operation. 



Good ...... 

Cough. 

Cough 

Good 

Confirmed in- 
valid. Rh. 
arthritis 

Good 



Very thin 
and cachetic 
Facial para- 
lysis 

Good, but 
extraction 

was followed 
by constant 
retching 



Usual operation . 

Capsule opened 

with cystotome 

Usual operation . 



Usual operation, 
but lids imme- 
diately sutured 

Usual operation . 



None , 



Soft matter left 



None , 



Cornea flaccid. 



1 


23 


1 


73 


M. 


R. 


2 


24 


1 


53 


M. 


R. 


3 


45 


1 


57 


F. 


R. 


4 


100 


2 


69 


F. 


L. 


5 


119 


2 


60' 


M. 


R. 


6 


147 


1 


46 


M. 


R 



Good . 



Black cata- 
ract 



Good 



Good , 



Small conjunc- 
tival flap. Small 
iridectomy. 
Capsule opened 
with cystotome 

Usual operation 



Lens large and 
difficult to ex- 
tract 



None , 



Hosted by GOOgle 



1892-1893] 



RESULTS OP CATARACT EXTRACTION. 



149 



Secondary 
complications. 



Immediate 
result. 



Remote 
result. 



Secondary 
operations. 



Complica- 
tions after 
secondary 
operations. 



Results 
after 2nd 
operation. 



Remarks. 



None , 



Suppuration 



6/60 
6/9 J. 6 

1/60 

5/60 J. 16 

6/24 

1/60 
5/60 



6/24 J. 8 

6/24 J. 6 
6/9 J. 1 

P.L. 

1/60 



Eviscera- 
tion 



Vitreous opacities. 
Disc pale. 



L en s m att er an d 
capsule. Still cap- 
sule. 



Lost from sympa- 
thetic ophthalmia 
following L. ex- 
traction. 

Capsule, &c. 



None 

Atropine,' de- 
lirium 

Serous iritis 
K. P. Hypo- 
pyon 

Iritis 

None 



6/24 J. 6 

6/9 J. 2 
6,12 J. 6 

1/60 



6/12 J. 8 
6/12 J. 4 



6/18 J\ 4 

6/6 J". 1 
P. L. 



Iridotomy 



4/60 J. 19 i 



P. L. 



L. sympathetic 
ophthalmia. 

R. disseminated 
choroiditis, but it 
did well after ex- 
traction six years 
ago. L., largo 
floating opacities. 

L., No. 2124 (year 

i88i»). 
Capsule. 

l'2 



Hosted by GOOgk 



150 



ON THE IMMEDIATE AND EEMOTE 



[1893 



55 



w* 



Eye. 



Age. 



7 


277 


2 


68 


F. 


8 


278a 


1 


49 


F. 


9 


313 


1 


81 


F. 


10 


331 


1 


67 


M. 


11 


340 


1 


76 


F. 


12 


476 


1 


69 


M. 


13 


501 


1 


80 


M. 


14 


525 


2 


72 


M. 


15 


543 


1 


69 


M. 


16 


567 


2 


47 


F. 


17 


588 


1 


55 


M. 


18 


654 


1 


87 


M. 


19 


761 


2 


74 


M. 


20 


764 


1 


54 


F. 


21 


784 


2 


58 


F. 


22 


901 


2 


68 


M. 


23 


936 


1 


77 


M. 


24 


951 


2 


71 


F 


25 


972 


1 


55 


M. 


26 


1094 


1 


70 


F. 


27 


11] A 


2 


77 


M. 


28 


1126 


1 


48 


F. 


29 


1137 


1 


41 


M. 



Sex, 



E, 



K. 



Condition 
of eye. 



Condition 
of patient. 



Operation. 



Good...... 



Hyper-mature 
cataract 

Good 

Myopic, hy- 
per mature 
cataract 

Good 



Unsteady. . 



Good 



Unsteady. . . 



Yery bad 
patient 



Good . 



Unsteady. . . 
Good 



Yery un- 
steady and 
broken 
down 

Good 



Usual operation . 

Scoop extraction 
Usual operation 



Complii ations 

at time 
of operation. 



None 

Iris buttonholeo 
None 

5 J *'• •' 

J) • 

)) * 

Soft matter left 
None 

,, ......... 

j) 

Soft matter left 

jj J* 
None 

Iris fell before 

knife 
None . . 



Hosted by GOOgle 



1883] 



RESULTS OF CATARACT EXTRACTION. 



151 



Secondary- 
complications. 



Immediate 
result. 



Remote 
result. 



Secondary 
operations, 



Complica- 
tions after 
secondary 
operations. 



Result 
after 2nd 
operation. 



Remarks. 



Iritis and K. P. 

None 

jj 

X. striata 

None 

Iritis and P. S. 



None 

Atropine irrita- 
tion 
Conjunct iyitis 
None 

Severe plastic 
iritis 

None 

Delirium. K. 

striata 
Suppurative 

iritis 

None 

Iritis and P. S. 



Hand- 
movement 

6/24 J. 1 
6/6 J. 1 

6/12 J. 6 
6/60 J. 15 



6/60 J. 12 
1,60 J. 20 



6/60 J. 



5/60 J. 16 



2/60 



6/60 

6/60 J. 15 
3/60 

6/60 J 16 
6/60 J. 16 

6/18 J. 1 
Hand- 
movement 



6/18 J. 12 

6/18 J. 4 
6/9 J. 1 

Hand- 
movement 
6/36 J. 4 
6/36 J". 15 



6/6 J. 1 
6/60 J. 14 


6/18 J. 6 
6/36 J. 15 


6/12 J. 1 


6/60 J. 12 


6/24 J. 12 


6/12 J". 4 


6/24 J. 10 


6/18 J. 6 
6/12 J. 1 


6j6 J. 1 
Fingers at 
2' J. 20 


6/6 J. 1 


6/6 J". 1 
6/18 eT. 6 



Excision. . 



Needling 



; J. l 



R., No. 45. Excised 
as an exciting sym- 
pathetic eye. 



Disc atrophic. 



R. excised. after 
cataract extrac- 
tion elsewhere. 
Capsule present. 

R., No. 1737 (year 
1891). L., vitreous 
opacities and cho- 
roiditis. 

Vitreous opacities. 
Wound re-opened 
3 months later. 
Yerj broken down 
subject. 

L. did well after 
extraction 7 years 
ago. 



L. extraction did 
badly elsewhere. 

L., No. 978 (year 

1892). 
R,, No. 331. 



R., No. 421 (vear 
1889). 



L., No. 992 (year 

1892). 



Hosted by G00gle 



152 



ON THE IMMEDIATE AND REMOTE 



[1893-1889 



















p/bJD 


iiyu. 


c/j o 




|S« 





30 



31 

32 
33 
34 



35 
36 

37 

38 



Ao-e. Sex. 



R. 



Condition 
of eye. 



Condition 
of patient. 



Operation. 



1153 


2 


76 


M. 


L. 


1 1 66 
1473 
1474 
1589 


2 
2 
1 
2 


54 
70 
55 
69 


F. 
M. 
M. 
M. 


L. 
L. 
R. 
L. 


1591 

1678 


1 

2 


67 
54 


M. 
F. 


R. 

R. 


1699 


2 


36 


F. 


R. 


1759 


1 


67 


F. 


L. 



G-ood . 



1 


32 


1 


71 


F. 


R. 


2 


144 


1 


66 


F. 


L. 


3 


266 


1 


65 


F. 


L. 


4 


383 


1 


69 


M. 


R. 


5 


600 


1 


69 


F. 


R. 


6 


695 


2 


62 


F. 


L. 


7 


758 


1 


59 


M. 


L. 


8 


781 


1 


62 


F. 


L. 


9 


83S 


2 


78 


M. 


L. 


10 


869 


1 


58 


M. 


L. 


11 


11C0 


2 


70 


M. 


R, 


12 


1L50 


1 


62 


F. 


R. 


13 


1227 


1 


69 


M. 


R. 


14 


1244 


2 


62 


M. 


R. 



Projection 
bad 



Brown cata- 
ract 
Good ....'. 



Very un- 
steady and 
broken 
down 

G-ood 

,, ...... 

Alcoho.ic . 

Most un- 
steady and 
broken 
down 

Good 

J, ...... 

,j ...... 

>> 

Good 

J) 

Very deaf . . 
Good 



Usual operation 



Complications 

at time 
of operation. 



None . 



Soft matter left 



Conjunctival flap. 

Medium sized 

iridectomy. 

Capsule opened 

with cystotome 
After preliminary 

iridectomy 
Usual operation . 



Peripheral cap 

sulotomy 
Usual operation . 



Soft matter re- 
mains 



Incision en- 
larged 
None 

>> 

Some soft matfcei 

left 
None .......... 

Wound enlarged 

Lens came 

away with 

difficulty 
Soft matter left 

None 



Hosted by GOOgle 



1893-1889] 



RESULTS OF CATARACT EXTRACTION. 



153 



Secondary 
complications. 



Immediate 
result. 



Remote 
result. 



Compliea- 
Secondary tions alter 
operations.! secondary 

operations. 



Kerato-iritis , 

None 

,, . . . . . • . 

Iritis 

None 



BCand- 
movement 



6/24 J. 8 
6/24 J. 12 
6/18 J. 12 
6/18 J. 12 



6/18 J. 4 
6/18 J. 12 

6/24 

Fingers at 
6" 



! 



6/24 J. 8 
6/12 J". 1 
6/6 J. 1 
6/12 J. 1 



6/6 J. 1 
6/18 J". 12 

6/12 J". 2 



Iridotomv 



Xeedling 



Result 
aft er 2nd 
operation. 



1/60 J. 19 



6/12 J. 8 



Remarks. 



R., No. 936. 



R., No. 764. 
R. } No. 476. 

R., No. 543. 



L. extracted else- 
where, did well. 

L., No. 1826 (year 
1892). 

Lens matter still 
present. 



Iritis and hy- 
pop^ on 



None 

Suppuration of 

globe 
None 

Iritis and post 
syn. 

None . 

)) 

Iritis 

>> * 

None 



J. 20 
6/60 J. 10 

4/60 

6/60 J. 20 

J. 18 

J. 16 

6/60 J. 12 
J. 20 



J. 18 


Needling 


None 


6/24 J. 4 


Vitreous opacities. 


6/6 J.'l 


Excision 


•• 


•• 


Excised 3 months 

after operation. 
Capsule. 
1st did well. 


6/9 J. 1 
6/60 


Needling 


•• 


6/36 


Still capsule pre- 
sent. 


6/36 


Needling 


None 


6/12 J. 1 


1st did well. 


J. 16 


•• 


•• 


•• 


Capsule. 


6/12 J. 1 
6/9 J. 1 


.. 


•° 


•• 


L. amblyopic. 


6/9 J. 12 










6/18 J, 8 


• • 


1 .. 


* . 


1 1st did well. 



Hosted by 



Google 



154 



ON THE IMMEDIATE AND REMOTE 



"1889-1890 



15 

16 
17 
18 



19 

20 
21 
22 
23 

24 



25 

26 

27 
28 

29 

30 
31 

32 

33 

34 

35 
36 






1260 

1346 
1350 
1352 



1383 

1401 
1441 
1475 
1507 

1536 



1587 

1753 

1898 
1967 

2003 

2007 
2067 

2108 

2129 
2203 

2211 

2275 



Eye, 



Age. 



Sex. 



Condition 
of eye. 



73 


F. 


L. 


73 

58 
70 


F. 
M. 
M. 


R. 
R. 
L. 


60 


F. 


L. 


71 
45 
60 
63 


F. 
F. 
F. 
F. 


L. 
L. 
R. 
R. 


68 


F. 


L. 


56 


F. 


L. 


36 


M. 


L. 


57 
64 


F. 
F. 


R. 
L. 


63 


F. 


L. 


68 
34 


F. 
M. 


R. 
L. 


76 


M. 


R. 


67 


F. 


L. 


46 


F. 


R. 


60 
69 


M. 
M. 


R. 

L. 1 



Hyperma- 

ture 
Good 

5) 

3) 

Oh. conjunc- 
tivitis 
Good 

53 •••••■ 
JJ 

Pus in lac. 

sac 
Vitreous 

changes 
Qood 

,, ...... 

)> 

Congenital 
aniridia. 
Glaucoma 

Myopia. 
Projection 
not good 

G-ood 



Condition 
of patient. 



Good , 



Diabetic. 
Good . . . 



Operation. 



Usual operation 



After preliminary 
iridectomy 

Usual operation . 



Complications 

at time 
of operation. 



After preliminary 

iridectomy 
Usual operation . 



After preliminary 
iridectomy 

Usual operation. 



Linear section. , . 

After preliminary 

iridectomy 
Usual operation . 



Non 



Soft matter left 



None . 



Some soft matter 

left 
None 



Some soft matter 

left 
None 



Soft matter left 



24 



70 



61 



R. 



L. 



Projection 
fair 



Good 



Cough 



Cold and 
cough 



Conj unctival flap. 
Iridectomy. 
Capsulotomy 
with cystotome 

Usual operation . 



None , 



Hosted by GOOgle 



1889-1890] 



RESULTS OF CATARACT EXTRACTION. 



155 



Secondary 
complications. 



Immediate 
result. 



Remote 
result. 



Secondary 
operations. 



Complica- 
tions after 
secondary 
operations. 



Result 
after 2nd 
operation. 



Remarks. 



None 

Slight iritis . . . 
j> < )) • • • 

Iritis and post 

syn. 
Small prolapse 

None. . , , 

jj 

Slight iritis . . . 
None 



6/60 J. 14 
6/60 J. 16 
6/12 J. 6 



6/24 J. 3 2 
16 



6/60, 
6/18 
3/60 
1/60 



J. 10 



6/60 

J. 14 

4/60 J". 16 
2/60 

6/24 J. 15 

6/36 J. .12 
6/24 J.. 4 



6/60 J. 12 

4/60 J. 12 

6/60 J, 16 

6/60 J. 16 
3/60 J. 15 



6/12 J. 8 

6/6 ' J. 1 

6/12 J. 1 

6/12 J. 1 
6/36 J. 10 
H/6 J. 1 

6/12 J. 1 

6/6 J. 1 

6/24 

6/60 



6/12 J. 1 
6/18 J. 1 



616 J. 1 
6/6 J. 1 

5/60 J. 19 



1 Needling 

2 Excision 



Needling 

Needling 
Needling 



Needling 



Suppura- 
tion 



None 

None 
None 



None 



Eye lost 



6/6 J. 1 

6/60 J. 12 
6/6 J. 1 



i J. 1 



L. did well. 

1st eye suppurated 

and was excised 

(No. 383). 



Choroiditis. 



Choroiditis near 
macula. Yessels 
small. 

R. did well. 



No note as to why 

Y. is not better. 
R. did well. 



L. did welJ. 

L. did well. 
R. did well. 



Some iritis . . . 


6/36 


6/6 J. 1 










None ........ 


6/60 


6/18 J". 4 


Needling . 


None .... 


6/6 J. 1 


R. did well. 



Hosted by " 



156 



ON THE IMMEDIATE AND REMOTE 



[189( 



— i CO 








r 












en £> 


Wye. 


Age. 


Sex. 


or 
T, 













Condition 
of eye. 



Condition 
of patient. 



Operation. 



Complications 

at time 
of operation. 



10 
11 
12 



13 
14 
15 



16 
17 

18 



19 

20 
21 
23 

24 

25 



"26 

27 

28 
29 



40 


1 


60 


F. 


E, 


70 
154 
226 


1 
1 
1 


68 
68 
60 


F. 
M. 
F. 


L. 
B. 
E. 


227 


2 


70 


F. 


E. 


217 
275 


1 
1 


60 
69 


F. 
F. 


E. 
L. 


355 


1 


73 


M. 


E. 


471 


1 


52 


F. 


E. 


506 


1 


70 


M. 


E. 


688 
702 
704 


1 
1 
1 


90 
48 
53 


M. 
M. 
M. 


E, 
E. 
L. 


856 

949 

1000 


2 
1 
1 


77 
38 
25 


M. 
M. 

M. 


L 
E, 
E. 


1002 


2 


69 


M. 


L. 


1031 
1032 
1231 


1 

1 
2 


70 
57 
37 


F. 
F. 
F. 


E. 
E. 
L. 


1268 


1 


53 


M. 


L. 


1300 


1 


62 


F. 


E. 


1467 


2 


61 


F. 


E. 


1481 


1 


48 


M. 


E. 


1635 
1653 


2 

2 


6"» 
53 


F. 
M, 


L. 
E, 



Good 

55 

55 ...... 

55 

55 

55 

-,f ...... 

55 

55 

Mucopuru- 
lent con- 
junctivitis 

Good 

Old iridecto- 
my, for 
iritis 

Good 

Myopia 
Good 

5) 

Hypermetro 
pic 

Cli. conjunc- 
tivitis 
Good 

55 ...... 

Ch. conjunc- 
tivitis 



Cli. broncli 

itis 
Good 

5' •'.... 

55 . . . . . 

5> • « • • • 

Feeble 

Quite deaf 
Good .... 

55 .... 

55 . • • • 

55 ••.. 

55 .... 

55 ♦... 

Rather 
feeble 

Good .... 



Usual operation . 



After preliminary 

iridectomy 
Usual operation . 



After preliminary 

iridectomy 
Usual operation . 



Aft er preliminary 

iridectomy 
Usual operation . 



Iridectomy dore 
after extraction. 
Iris was much 
bruised 

Usual operation . 

Incision enlarged 
Usual operation . 



Escape of vit- 
reous 
Sticky lens 



None , 



Soft matter left 



None 



Iris fell in front 

of knife 
Cortex very 

sticky 
None . . * 



None 

Lens difficult to 

deliver 
None 



Hosted by 



Google 



1890] 



RESULTS OP CATARACT EXTRACTION. 



157 





Secondary 
complications. 


Immediate 
result. 


Remote 
result. 


Secondary 
operations. 


Complica- 
tions after 
secondary 


Eesult 
after 2nd 
operation. 


Remarks. 












operations. 






Slight iritis . . . 


6/60 














33 >) 


6/60 J". 8 
6/18 


6j6 J. 1 






•• 


R. did well. 




None 


6/60 J. 10 


6/9 J. 2 












Iritis andP.S.. 


6/24 J. 10 
6/36 


6/24 J. 4 
8/9 J. 1 








L. did well. R. disc 
pale. Vitreous 
opacities. 




Primary suppi. 


ration 


No P.L. 




• * 


• * 


R. blind eye. Old 
rupture. L. globe 
shrunken. 




None 


Fingers at 
12" 


6/18 J. 15 


Needling . 


None .... 


6/9 J. 1 






Small prolapse 


6/36 














of iris 
















Iritis and P.S. 


6/24 


6j6 J". 1 


Excision. . 






Iridocyclitis caused 
globe to shrink 
and eye to become 
blind. 




None 

33 


6/9. 

6/6 


6/6 J. 1 
6/5 J. 1 












33. 


6/12 J. 6 


6/60 J. 12 


Needling . 


None .... 


6/12 J. 1 






,5 ........ 


6/9 










R. did well. 




» 


6/18 J. 10 


6/18 J. 10 
J. 20 


Needling 2 

1. needling 

2. iridoto- 
my 


None .... 

33 • • • • 


6/6 J. 1 
6/24 J. 12 






" 


6/36 




•• 


•* 


•• 


R. vitreous, full of 
opacities. 




,, 


6/60 J. 1 


6/18 J. 1 








Myopic changes. 




Slight iritis . . . 


6/18 


6/60 


Needling 2 


None .... 


6/6 J. 1 






K . striata .... 


6/18 J". 4 


6/9 J. 1 


. 


. .. 


•• 


R. did well. 




None 


6/12 J. 1 














Iritis and many 


2/60 


6/24 J. 12 


Needling . 


Iritis .... 


6/36 






P.S. 
















Some iritis . . . 


6/36 


6/12 J. 1 


.. 


.. 




L. did well (No. 




None 


6,6 J. 2 


6/9 J". 1 








1383, year 1889) 




33 * * • 


. , 


6/12 J. 6 


Needling . 


None .... 


6/6 J. 1 


R. did well. 




" 


6/12 


6/60 


Needling . 


., .... 


6/6 J. 1 


L. did well. (No. 



Hosted by GoOgle 



158 



ON THE IMMEDIATE AND REMOTE 



[1890-1891 



03 -1-3 








R. 


'cL'Sjo 


Eye. 


Age. 


Sex. 


or 


co 0J 








L. 


£* 











Condition 
of eye. 



Condition 
of patient. 



Operation. 



30 


1691 


1 


68 


F. 


L. 


31 


1695 


1 


72 


M. 


R. 


32 


1839 


2 


71 


M. 


L. 


33 


1927 


1 


72 


M. 


R. 



Choroidal 
atrophy 

Good 

Ch. conjunc- 
tivitis 

G-ood 



Good , 



Usual operation . 



Complications 

at time 
of operation. 



Soft matter re- 
mained 
None ,...,, 



Soft matter diffi- 
cult to get away 



1 


208 


2 


63 


F. 


R. 


2 


226 


1 


77 


F. 


R. 


3 


240 


1 


79 


M. 


R. 


4 


505 


1 


81 


F. 


L. 


5 


506 


1 


65 


F. 


R. 


6 


576 


2 


77 


F. 


L. 


7 


620 


2 


69 


F. 


L. 


8 


645 


1 


60 


M. 


R. 


9 


741 


1 


57 


F. 


R. 


10 


812 


1 


68 


F. 


R. 


11 


815 


1 


76 


M. 


L. 


12 


859 


1 


64 


F. 


R. 


13 


911 


2 


71 


F. 


L. 


14 


934 


1 


63 


F. 


L. 


15 


944 


1 


59 


h\ 


L. 


16 


1126 


2 


64 


F. 


R. 



Choroiditis 



Brown cata- 
ract 

Old case of 
interstitial 
keratitis 

Good 

Cornea ne- 
bulous. 
Lens loose 

Good 

Old iridec- 
tomy for 
iritis. 

Brown cata- 
ract 

Good 

Myopic .... 
Good 



Good , 



Diabetic . . 



Conjunctival flap 
Iridectomy. 
Capsule opened 
with cystotome 

Usual operation . 



Incision enlarged 
Usual operation . 



Wound enlarged 
Usual operation . 



None 

?> - 

Rather difficult 
to extract. 

Soft matter left. 
Outer angle of 
iris entangled 

None 

Lens difficult to 

extract 
None 



Hosted by GOOgle 



1 

X 

1890-189>1] 


RESULTS OF ( 


3ATARACT 


EXTRACTION. 


159 




\ 

Secondary 
complications. 


llmmediate 
\result. 


Remote 
result. 


Secondary 
operations. 


Complica- 
tions after 
secondary 
operation. 


Result 
after 2nd 
operation. 


Remarks. 




None 


1/60 


> 

2/60 




.. 




Choroidal atrophy. 




„ 


6j6 

6/60 J. 16 


6/18 
6/60 J. 16 


Needling 2 
Needling . 


None .... 


6/12 
6/6 J. 1 


R. did well. 




Iritis and lens 
matter pre- 
sent P.S. 


• • 


616 J. 1 










I 






None 

>' 


3/60 

3/60 

6/36 


6/18 








L., No. 1691 (year 
1890). In both 
there is choroidal 
atrophy. 

Cornea nebulous. 




K. striata 

Suppuration . . 


6/60 


6/24 J. 4 


Excision. 










None 


3/60 
6/36 

3/60 J. 18 


6/12 


.. 






R,, No. 226. 
R., No. 2007 (year 
1889). 

Disseminated 
choroiditis. 




j> • • • 


6/18 J. 4 


6/36 J. 8 


Needling . 


, , 


6/12 J. 1 




' 


>j 

Post synechia. 


6/18 J. 6 

6/18 

6/60 


6/60 J. 16 


•• 




•• 


R., No. 1031 (vear 
189U). L. wants 




Slight iritis. . . 
None 


6/36 
6/60 


6/36 
6/18 


Needling 2 


•• 


6/12 J. 1 


needling. 

L., No. 781 (year 
1S89). 


1 












Ho< 


ted by Google 



160 



ON THE IMMEDIATE AND REMOTE 



1 

[1^91-1892 



+ 



i— i <o 








R 


03 -+= 










'§/§> 


Eye. 


Age. 


Sex. 


or 
Ti 


op^ 










w 











Condition 
of eye. 



Condition 
of patient. 



Operation. 



Complications 
1 at time 
of operation. 



— 7C~~ 

Usual c peration 



17 



18 
19 



20 
22 
23 



2t 



1161 



1341 
1447 



1451 
1524 
1610 

1655 



1755 



69 



68 



M. 



L. 



L. 



Hyper mature 
cataract 

Good 

)) 

Hypermature 

cataract 
Good .... 



Unsteady. . . 



Good 



Rather feeble 
Good .... 



V > 



A little vitreous 
lost 

Soft matter left 
None 

j? • • • • 

>j 

a 

Lens difficult to 
deliver. 

None 

None 

n « • • • 

)> * ' 

)> . » . 

)) 

5) • 

>) 

Difficult to de- 
liver 

None 

Much soft matte 
remained 



1 


95 


1 


74 


F. 


L. 


2 


367 


1 


59 


F. 


R. 


3 


422 


1 


68 


F. 


L. 


4 


441 


1 


59 


M. 


L. 


5 


545 


1 


76 


F. 


L. 


6 


647 


1 


52 


M. 


R. 


7 


840 


1 


72 


M. 


R. 


8 


883 


2 


59 


M. 


R. 


9 


869 


1 


66 


M. 


L. 


10 


911 


2 


73 


F. 


R. 


11 


926 


2 


74 


F. 


L. 


12 


1067 


1 


72 


F. 


R. 


13 


1467 


1 


67 


M. 


L. 


14 


1519 


1 


66 


F. 


R. 



L. ptosis . . 



Good, 



Hypermature 
cataract 

Myopic .... 



Epiphora 
Good .... 



Good . 



Feeble . 
Good . . 



Unsteady. 
Good .... 



Cough , 
Good . , 



Conjunc 
Irideet o 
sule op 



tival flap. 

my cap- 

ened with 



cystotome 
Usual o peration 



Scoop extraction 
Usual o Deration 



Hosted by GOOgle 



1891-1892] 


RESULTS OF ( 


3ATARACT 


1 EXTRACTION. 


161 




Secondary- 


Immediate 


Eemote 


Secondary 


Complica- 
tions after 


Result 






complications. 


result. 


result. 


operations. 


secondary 
operation. 


operation. 




Slight iritis . . . 


6/36 


4/60 








R. extraction 6 years 
















ago did fairly well. 
















In both large vitre- 
















ous opacities. 




None 


6/24 


616 












K. striata 


3/60 


6/6 J. 1 


• * 


• • 


• • 


L. operated upon 
five years ago. It 
did well. 




None 


6/36 


6/24 J. 12 


Needling None .... 


6/6 J. 1 






,, 


6>60 


6/6 












» • 


3,60 


6/36 J. 12 


Needling 


}■> • • 


6/9 J. 1 


Tay's choroiditis. 




Prolapse of 


.. 




Iridectomy 










inner angle 
















-of coloboma 
















Inner angle 


6/36 


6/36 












adherent to 
















wound 















Suppi 


ration 




1. Wound 
cauterized 

2. Excision 


•• 


•• 


Primary suppura- 
tion. 


None 


6/24 


6/6 J. 1 










Prolapse of 


6/24 


.. 


Iridectomy 


Severe 


Hand- 


Three months after 


inner angle 






for pro- 


iritis 


movement 


extraction, kerato- 


of iris 






lapse. 
Iridotomy 






iritis developed. 


ITyph tenia . . . 


6/24 J. 8 


6/6 J. 1 










None 


2/60 












„ 


6/9 J. 1 


6/24 J. 12 


Needling 


, , 


6/6 J. 1 




Post synechia . 


6/24 


6/24 J. 4 


2 Needling 




6/18 J. 1 




None 

>> • • • 


6/24 
6/24 
6/36 


6/6 J. 1 
6/6 J". 1 


•• 






R., No. 441. 

R. cataract extracted 
11 years ago. Did 


Slight iritis . . . 


1/60 


•• 


•• 


•• 


•• 


badly. 
R. did well. L. lens 
matter and capsule 
present. 


,, ... 


•• 


6/24 J. 10 


2 Needling 




6/18 J. 1 




None 


6/18 


6/18 J. 6 










j> • • • 


tfand- 


Hand- 


Needling 


Eye very 


6/6 J. 1 


L. lost after small- 




movement 


movement 




in it-able 




pox in childhood. 



Hosted by GOOgle 



162 



ON THE IMMEDIATE AND REMOTE 



[1892-1893 



Hye. 



Age. 



Sex. 



Condition 
of eye. 



Condition 
of patient. 



Operation. 



Complications 

at time 
of operation. 



15 

16 
17 

IS 
19 

20 



21 
22 



1551 


2 


67 


M. 


R. 


1615 


1 


74 


F. 


R. 


1642 


1 


62 


F. 


R, 


1661 


1 


73 


F. 


L 


1693 


1 


75 


F. 


L. 


1771 


2 


67 


M. 


R. 


1777 


2 


69 


F. 


R. 


1590 


1 


64 


M. 


L 



Good, 



Good , 



Usual operation . 



None 



10 
11 

12 



13 



14 



133 


1 


66 


M. 


L. 


157 

266 


1 
2 


44 
68 


F. 
F. 


R. 
L. 


267 


1 


65 


F. 


L. 


310 


2 


59 


F. 


R. 


326 
359 

392 


1 
1 

2 


73 
52 

74 


F. 
M. 
F. 


R. 
R. 
R. 


448 


1 


68 


M. 


L. 


486 
599 


1 
2 


70 
70 


M. 
F. 


R. 
R. 


664 


2 


68 


F. 


R. 


686 


1 


73 


M. 


R. 


752 


1 


29 


F. 


B 



Ch. conjunc- 
tivitis 



Hypermature 

Projection 

not good 

Good 

» 

i> 

Incomplete 

cataract 
Gool 



Alcoholic, 
gouty 



Mentally 
unsound 
Good 

» • • • • • 

Unsteady . 

Rheumatic, 
gouty 

Good 

Not good . . 

Good 



Fairly good. 



Conjunctival flap. 
Iridectomy; cap - 
sulotomy with 
cystotome 

Usual operation . 



After preliminary 

iridectomy 
Usual operation . 



Soft matter left 

None 

>> * • • 

Soft matter left 

None 

Soft matter left 
None 

Soft matter left 

None 

Vitreous lost. . . 

None 



Hosted by 



Google 



1892-1893] 



RESULTS OF CATARACT EXTRACTION. 



163 





Secondary- 
complications. 


Immediate 
result. 


Remote 
result. 


Secondary 
operations. 


Complica- 
tions after 
secondary 
operations. 


Result 
after 2nd 
operation. 


Remarks. 




None 


6/36 


6/9 J. 1 


.. 






L., No. 1341 (year 
1891). 

Still dense capsule. 




Wound bulged 
None 

>> 

Atropine irri- 
tion 


6/60 J. 15 
6/24 JT. 6 
6/60 
6/60 

Fingers at 
9" 


6/36 J. 8 
6/18 J. 2 
6/24 J. 6 
6/60 J. 12 
Hand- 
movement 


Needling 

Needling 3 
Needling 


None 

Eye very 
irritable for 


6/9 J. 4 
6/36 J. 15 




None 


6/24 
6/24 J. 4 


6/ 18 J. 6 
6/6 J. 1 


•• 


some time 
after iridec- 
tomy 


•• 


L., No. 934 (\ear 
1891). 



None . 



Delirium . 
None . . . . 



Hyphaeiur. 
None 



Plastic iritis , 
K. striata. . . , 



Haemorrhage 
at macula 



VOL. XIV. 



6/24 J. 12 



6/18 J. 8 
6/24 J. 4 



1/60 J. 


20 


6/12 J". 


8 


2/60 J. 
6/24 J. 
6/24 J. 


19 
12 
12 


Finger 
9" 


3 at 


3/60 J. 20 
Fingers at 
12" 


1/60 J. 


20 


2/60 J. 


19 


6/36 J. 


12 



Needling 
Needling 



Needling 



6/6 J. 1 



6/24 J. 6 

1/60 J. 19 

6/6 J. 1 

6/24 
6/9 J. 1 
6/9 J. 1 

6/24 J. 15 

P.L." 

1/60 J. 20 

6/6 J. 2 



6/24 J. 1 2 Needling 3 Eye vein 
I | irritable 



Needling 



Needling 



6/12 J. 2 

6/12 J. 2 



6/12 J. 4 



6/6 J. 1 



1/60 



6/6 J. 1 



R. cataract extracted 
nine years ago. 
Did well. 



No. 1524 
1891). 



(year 



Vitreous opacities. 

L. suppurated. No. 

95 (year 1S92). 



Capsule, &o. 

L. did badly. No. 
422 (year 1892). 

L. extraction. No. 
1610 (year 1891). 
R. central choro- 
iditis. 

Sight destroyed by 
macular hemor- 
rhage 11 months 
after extraction. 



M 



Hosted by V^OOQlC 



1(54 



ON THE IMMEDIATE AND REMOTE 



[1893 



fc 



W 



Eye. 



Age. 



15 



16 

17 

18 

19 



823 



757 

947 
941 

983 



20 1009 



21 

22 



23 

24 
25 

26 

27 
28 



29 

30 

31 

32 
33 
34 

35 
36 

37 



1045 
1103 



1124 

1148 
1177 
1250 

1463 

1464 



1469 

1486 

1532 

1576 
1629 
1630 

1676 
1712 

1711 



Sex, 



R, 



Condition of 
eye. 



Condition of 
patient. 



64 

61 

68 

52 

36 

74 

55 
62 

74 

62 
62 
79 

70 

60 

58 

64 

57 

72 
67 
74 

53 
65 

60 



M. R. G-ood 



Good 



M. 

M. 

F. 

M. 
M. ! R. 



Congenital 
aniridia 
glaucoma 

G-ood 



M. 

M. 

F. 
F. 

M. 

M. 

F. 

M. 
F. 
F. 

F. 
M. 

F. 



L. 
R. 

L. 

R. 

L. 



Diabetes. 



Good 



Hypermature 
cataract 



Good 



Unsteady 
Good .... 



Hypermature 
cataract 

Amber-col- 
oured cat a 
raet with 
cholesterine 



Operation. 



Unsteady 
Good .... 



Complications 

at time 
of operation. 



Usual operation . 



Lens matter left 



Iris fell before 
knife, a piece 
afterwards re- 
moved 

Usual operation - 



None 



Soft matter re- 
mained 



None 



Lens difficult to 
deliver 



None 

Lens difficult to 

deliver 
None 



Lens difficult to 
deliver. Some 
chippy pieces 
left 

None 



Soft matter left 
None 



r v i : 



HVtoflhyV-lOOgfP 



1893] 



RESULTS OF CATARACT EXTRACTION. 



165 



Secondary 
complications. 



Immediate 
result. 



Remote 
result. 



Secondary 
operation. 



Compl.ca- Result 

hons after affcer 2nd 
secondary t;< 

operations. ' x 



Re marks. 



None 

Prolapse of 
outer angle 
of iris 

None 

)) ' 

None 

Purulent iritis 
Atropine irri- 
tation 
») >> 

None 

n 

)j ' 

Some iritis and 
P.S. 

Much K. s" . . 

Atropine irri- 
tation 

None 

Atropine irri- 
tation 

None . . 



Hand- 
movernent 

4/60 J. 19 

6/12 J. I 
6/12 J. 1 

6/24 J. 8 



Fingers at 
4" 

6/18 J. 12 

J. 16 



1/60 J". 20 

3/60 J. 20 
6/36 J. 19 
6/60 

6/60 J. 19 

5/60 J. 15 



J. 15 

4/60 J". 19 

6/24 J. 12 

6/36 J. 14 
3/60 J. IS 
6/24 

6/15 J. 6 
6/12 J. 10 

6/36 J. 15 



6/36 J. 20 



6/9 J". 1 
6/9 J. 1 

6/24 J. 2 



6/6 J. 1 
6/9 J. 4 

6/60 J. 12 

6/36 J". 19 
6/6 J. 1 

6/12 J. 1 

6/6 J. 1 



6/60 J. 19 
6/6 J. 1 

6/6 J. 1 

6/24 J. 6 
6/6 J. 1 

6/24 J. 8 
6/12 J. 1 



Needling 



None 



Needling 



6/12 J. 4 



None , 



6/6 J. 2 



Vitreous full of 
cholesterine crys- 
tals. 

R. did well after ex- 
traction elsewhere. 

R, No. 647 (year 

1892). 
L. No. 2067 (year 

1889). 



R. No. 840 (Tear 

1892). 
Disc atrophic. 
Vitreous opacities. 



Vitreous opacities 
and capsule. 



R. did well after ex- 
traction several 
years ago. 

Cholesterin in vit- 
reous R. No. 823. 



R. did well after ex- 
traction elsewhere. 



M 



Hosted by 



Google 



166 



38 
39 



ON THE IMMEDIATE AND REMOTE 



f-i 










c3 •+£ 








R. 


'EL'SjD 


Eye. 


Age. 


Sex. 


or 










L. 


W 










1733 


2 


67 


M. 


R. 


1943 


1 


59 


M. 


L. 



Condition 
of eye. 



Qood , 



Condition 
of patient. 



Unsteady 
aood .... 



Operation. 



Usual operation 



[1893-1881 



Complications 

at time 
of operation. 



None , 



Much difficulty 
in getting lens 
away 



J 


10 


2 


137 


3 


153 


4 


178 


5 


191 


6 


237 


7 


352 


8 


476 


9 


,, 


10 


553 


11 


646 


12 


700 


13 


9S1 


It 


1023 


15 


1025 


16 


1090 


17 


1164 


18 


1187 


19 


1218 


20 


1324 


21 


1454 


22 


1456 


23 


1467 


21 


1491 



25 : 1492 

26 ; 1504 

27 1557 



2 


53 


F. 


L. 


1 


75 


M. 


L. 


2 


61 


M. 


L. 


2 


63 


M. 


L. 


2 


70 


F. 


L. 


1 


72 


M. 


R. 


1 


71 


F. 


L. 




72 


M. 


R. 

L. 


1 


60 


F. 


R. 


] 


50 


l\T. 


L. 


1 


62 


F. 


L. 


1 


69 


F. 


R. 


1 




F. 


L. 


2 


89 


F. 


L. 


1 


70 


F. 


L. 


2 


60 


M. 


L. 


1 


64 


F. 


L. 


1 


32 


M. 


L. 


2 


59 


M. 


R. 


2 


32 


M. 


R. 


1 


80 


M. 


R. 


1 


75 


F. 


L. 


2 


60 


F. 


R. 


2 


68 


F. 


R. 


1 


68 


M. 


L. 


1 


62 


M. 


R. 



aood. 



Good. 



Heart disease 
aood. . . . 



Conical cor- 
nea 
aood 



Pterygium 
aood 



Cough 
aood. . 



Ch. bron- 
chitis 
None 



Eczema . . . 
ao.od 



Feeble . . . 
Couty . . , 



Conjunctiva] flap, 
Iridectomy. 
Capsule opened 
with cystotome 

Usual operation. 



After preliminary 
iridectomy 



No iridectomy . . 



Usual operation 
no iridectomy 



None 

Vitreous lost 

None , 

Vitreous lost 

None 



Hosted by 



Google, 



1893-1889] 



RESULTS OF CATARACT EXTRACTION. 



Ifi7 



Secondary 
complications. 



Immediate 
result. 



Remote 
result. 



Secondary 
operations. 



Complica- 
tions after 
secondary 
operations. 



Result 
after 2nd 
operation. 



Remarks. 



K. striata . . 



3/60 J. 20 
6/60 J. 8 



6/9 J. 4 



L. No. 1590 (year 
1892). 



Slight iritis. . 

Acute iritis . 
None 

>) 

Iritis 

None 

Iritis 

None 

j> 

Slight iritis . 
None 

Slight iritis 
None 

Iritis and 

haemorrhage 
None 

Slight iritis . 

None 

Iritis 

,, ....... 

Prolapse of iris 

Tritis 

Slight iritis . 

Iritis o 



6/60 J. 12 



6/36 J. 8 
6/36 J. 12 
/ J. 20 



2/60 



6/60 J. 14 
6/24 J. 16 
6/60 J. 16 
3/60 J. IS 



3/60 
3/60 



J. 20 



1/60 



J. 12 

3/60 
6/9 J. 1 
6/60 J. 20 
1/60 
1/60 



6/36 J 12 
6/60 J. 16 



6/60 



6/6 J. 1 
6/12 



6/6 J. 1 
6/18 J. 4 
3/60 

6/12 J". 1 
6/36 J. 14 
6/12 J. 1 
3/60 

6/18 J. 1 
6/36 J. 4 

6/36 J. 18 



6/36 J. 10 
6/12 J. 6 



4/60 J. 20 
6/24 J". 8 
6/6 J. 1 



6/24 J. 12 



Needling 

1. Needlinj 

2. capsule 
extraction 



Needling 
Needling 
Needling 

Needling 



Needling 
Needling 

Needling 

Iridectomy 
for pro- 
lapse 



Grlaucoma 



6/24 J. 6 
6/12 



6/24 
6/9 J. 1 

6/24 



1/60 



6/9 J. 1 
6/9 J. 1 



6/36 J. 14 
6/24 J. 12 
6/6 J. 1 



R. did well. 



Vitreous opacities. 



1st No. 263 (1889) 
No. 1218. 



No. 1023. 



Hosted by 



Google 



168 



ON THE IMMEDIATE AND REMOTE 



[1889-1890 



O r^ 









R. 


Eye. 


Age. 


Sex, 


or 
L. 


1 


48 


M. 


L. 


2 


75 


F. 


R. 


2 


64 


F. 


R/ 


1 


57 


F. 


R. 

L. 


1 


G7 


M. 


L. 


2 


67 


F. 


L 


.]_ 


67 


M. 


R. 


1 


65 


F. 


R. 


1 


63 


F. 


L. 


L 


62 


F. 


L. 



Condition 
of eye. 



Condition 
of patient. 



Operation. 



Complications 
at time of 
operation. 



28 


1693 


29 


1725 


30 
31 
32 
33 
34 


1726 

1778 
1778 
1793 
1833 


35 
36 
37 


1932 
2122 
2283 


38 


2286 



Old iritis. 
Iridectomy 
down and 
in 

Good »..,.. 



Cough 



Good.... 

Albuminuria 
None .... 



Extraction 
downwards 



Usual operation 
No iridectomy 



Usual operation 
with iridectomy 

Without iridec- 
tomy 



Vitreous lost 



None 



1 


80 


1 


63 


M. 


L. 


2 


105 


1 


75 


F. 


R. 


3 


146 


1 


57 


F. 


R. 


4 


191 


2 


65 


F. 


L. 


5 


291 


1 


56 


F. 


R. 


6 


298 


2 


50 


M. 


L. 


7 


381 


2 


65 


F. 


R. 


8 


505 


2 


57 


M. 


L. 


9 


555 


2 


61 


F. 


R. 


10 


599 


2 


57 


F. 


L. 


11 


618 




58 


F. 


L. 


12 


618 




5J 


?) 


R. 


13 


624 


2 


63 


M. 


L. 


ll- 


6*6 


2 


61 


F. 


L. 


lS 


709 


1 


69 


F. 


R. 


16 


829 


2 


50 


F. 


L. 



Good, 



Morgagnian 

cataract 
Good 



Good , 



Hemiplegia 

Congenital 
syphilis 



Good, 



Conjunctival flap, 
No iridectomy. 
Capsule opened 
with cystotome 

Usual operation 



With iridectomy 



No iridectomy . 

". . " " 

With iridectomy 

No iridectomy 
With iridectomy 

3) J) • 

No iridectomy . 
With iridectomy 



None , 



Hosted by GOOgle 



1889-1890] 



RESULTS OP CATARACT EXTRACTION. 



169 





Secondary 
complications. 


Immediate 
result. 


Remote 

result. 


Secondarj 
operations. 


Complica- 
tions after 
secondary 
operations. 


Hesult 
after 2nd 
operation. 


Remarks. 




None 

Iritis 

Slight iritis - . 

None 

Slight iritis . . 

Hyphsema. . . . 

None 

>) * • 

}■> * 


/ J. 20 

J". 12 

J. 10 

6/36 J. 8 

6/24 J. 12 
1/60 

6/60 J. 12 
6/60 J. 16 

6/60 J. 15 


6/24 J. 12 

6/36 J. 12 
6/9 J. 2 
6/24 J. 12 

6/18 J. 2 

3/60 J. 14 
6/6 J. 1 


Needling 
Needling 

Needled . 
Capsule 
extraction 
Needling . 


•• 


6/24 J. 12 
6/18 J. 1 

6/24 J. 15 
6/9 J. 2 

4/60 J. 15 


No. 146V. 
No. 1187. 



Prolapse of iris. 






Iridectomy 




6/6 J. 1 




Slight iritis 






for pro- 
lapse 








None 


6/18 J. 6 












Prolapse of iris 


6/60 J. 12 


6/60 J". 12 


Iridectomy 
for pro- 
lapse 




6/9 J. 1 




Slight iritis . . . 


6/36 


6/6 J. 1 


r 






R., No. 89. 


Gtood 


6/9 J. 1 


6/6 J. 1 
6/9 J. 1 










G-ood 


6/24 




1. Capsule 
extrac- 
tion. 

2. Excision 


Vitreous 
lost. Iri- 
docycli- 
tis 


6/36 J. 8 


Eye inflamed and 
degenerated later. 


>} 


6/12 


6/60 


Needling 




6/6 J. 1 


R. (year 1888). 


} 


6/24 J. 10 


6/9 J. 1 








L. (year 1887). 


Slight iritis . . . 


6/24 


6/12 J. 6 


.. 


.. 


.. 


R. (year 1890). 


None 


6/6 


6/6 J. 1 










5J 


6/24 


6/36 


Needling 




6/9 J. 1 




, , 


6/36 












J? 


6/36 


6/60 J". 15 


Needling 




6/18 J. 2 


R. (year 1889). 


,, 


6/24* 


6/12 J. 2 










Slight iritis . . . 


6/6 J. 1 













Hosted by ViOO<? IC 



170 



ON THE IMMEDIATE AND REMOTE 



[1830-1891 



O 











E. 


•"tfl .^ 


i£ye. 


ige. 


Sex. 


or 


'£ &, 








I, 


£& 










i 1 











Condition 
of eye. 



Condition 
of patient. 



Operation. 



17 


985 


1 


36 


F. 


L. 


18 


986 


1 


75 


F. 


R. 


19 


1023 


1 


60 


F. 


R. 


20 


1256 


2 


35 


M. 


R. 


2L 


1276 


2 


82 


M. 


R. 


22 


1418 


2 


75 


F. 


L. 


23 


1523 


1 


73 


F. 


R, 


24 


1548 


1 


4S 


F. 


L. 


25 


1619 


1 


78 


M. 


R. 


26 


1799 


1 


64 


M. 


L. 



Good . 



Good . 



Morgagnian 
Good 



Ch. conjunc- 
tivitis 



Diabetes. . . 



Good , 



Heart disease 
Good .... 



Complications 

at time 
of operation. 



No iridectomy . . None 



With iridectomy 
No iridectomy 



9 
10 
11 
12 
13 

14 

15 
16 



41 



63 

82 | 
112 ! 
167 i 



186 

273 


1 
1 


! 274 


1 


289 


1 


416 


1 


440 


2 


452 


1 


455 


2 


496 


1 


556 


1 


568 


o 



50 


M. 


R. 


64 


M. 


R. 


76 


F. 


L. 


59 


F. 


L. 


69 


F. 


R. 


72 


M. 


R. 


73 


M. 


L. 


63 


M. 


L. 


46 


M. 


L. 


60 


M. 


L. 


58 


F. 


L. 


65 


F. 


L. 


50 


M. 


L. 


77 


F. 


R. 


60 


F. 


L. 


70 


F. 


L. 



Good ; Cough. 



Good . 



Scirrhus of 
breast 

Gouty 

Good 



Deaf 
Good . 



Conjunctival nap. 
After prelimin- 
ary iridectomy, 
capsule opened 
with cystotome 

Usual operation. 
No iridectomy 



Corneal section . 

Usual operation. 

No iridectomy 

With iridectomy 



No iridectomy. . . 

>» »> 

With iridectomy 
After preliminary 

iridectomy 
With iridectomy 



No iridectomy. . 



Vitreous lost. 



Good, 



Vitreous lost. 
None 



Vitreous lost. 



None , 



Hosted by GOOgle 



1890-1891] 



RESULTS OF CATARACT EXTRACTION. 



171 













Complica- 


Result 






Secondary 


Immediate 


Remote 


Secondary 


tions after 


after 2nd 


Remarks. 




complications. 


result. 


result. 


operations. 


secondary 
ouerations. 


operation. 






Prolapse of iris 


6/12 


6/60 J. 18 


1. Iridec* 
tomy for 
prolapse. 


.. 


6/12 J, 1 


























2. Needling 










Prolapse of iris 


6/18 J. 6 


* * 


Iridectomy 
for pro- 
lapse 


" 


6/9 J. 1 






Suppu 


ration 


.. 


Excision 










None 


6/12 J". 6 














Prolapse of iris 






Iridectomy 
for pro- 
lapse 




6/60 J. 20 


Mental condition 
very bad. L. ex- 
tracted 17 years 
ago. 




None 


6/60 

6/12 


6/36 


Needling 




6/12 J. 1 


R., No. 986. 




„ 


6/36 


6/24 


Needling 2 




6/24 






)5 


6/60 


6/9 J. 2 











None ........ 


6/18 


6/9 J. 1 










Good 

)> 


6/24 


6/6 J. 1 




•• 


•• 


L. extracted 1890. 


Ant. synechia . 
Prolapse of iris 

None 

Slight iritis.. . 


6/9 J. 1 

6/12 
6/12 


6/6 J. 1 


Iridectomy 
for pro- 
lapse 


•• 


6/6 J. 1 




None 

Iritis 

None 

Iritis 


4 '60 
6,24 
6/36 
6/36 

6/12 


6/6 J. 1 
6/6 J. 1 
3/60 
6/6 J. 1 

6/12 


Needling 


•• 


6/6 J. 1 


R. extracted 1890. 
No. 41. 


Purulent iritis, 
&c. 

None 

Purulent iritis 


P.L. 

6/9 J. 1 
Hand- 
movement 


P.L. 

6/9 J. 1. 
P.L. 


.. 


.. 




No. 167. 



Hosted by 



Google 



172 



ON THE IMMEDIATE AND EEMOTE 



[1891 



i— I o 

=3 -4^ 








E. 


"EL'Sjd 


Eye. Age. 


Sex. 


or 


u2P3 






L. 


w 











Condition 
of eje. 



Condition 
of patient. 



Operation. 



IV 


590 


1 


69 


F. 


L. 


18 


610 


2 


70 


M. 


L. 


19 


655 


1 


43 


M. 


L. 


20 


682 


1 


75 


F. 


L. 


2L 


706 


1 


76 


F. 


L. 


22 


721 


1 


65 


M. 


L. 


23 


735 


1 


64 


F. 


L. 


24 


736 


1 


72 


F. 


E. 


25 


767 


1 


51 


F. 


L. 


26 


809 


1 


75 


M. 


L. 


27 


821 


1 


61 


M. 


E. 


28 




2 






L. 


29 


890 


1 


67 


F. 


R, 


30 


891 


1 


61 


h\ 


E. 


31 


924 


1 


47 


M. 


L. 


32 


925 


1 


61 


M. 


L. 


33 


951 


2 


83 


M. 


L. 


34 


972 


1 


57 


M. 


L. 


35 


973 


2 


72 


M. 


L. 


36 


1003 


1 


70 


F. 


L. 


37 


1021 


1 


60 


F. 


L. 


38 


1027 


1 


65 


M. 


E. 


39 


1042 


1 


59 


F. 


E. 


40 


1052 


1 


53 


F. 


E. 


41 


1080 


1 


76 


F. 


E. 


42 


1202 


1 




M. 


E. 


43 


1242 


2 


75 


F. 


E, 


44 


1300 


1 


61 


M. 


E. 


45 


1391 


1 


73 


M. 


R. 


46 


1437 


1 


66 


F. 


E. 



Good 



Projection 
bad 



Good. 



Diabetes . 
Good 

Diabetes . 

None 
,, • • . . 

Influenza . 

Good . . . . 
,, . . . . 

j, . . . . 

Ataxic . . . 

Good .... 

Diabetes. 
Gout 

Deaf 

Good 



No iridectomy . . 
After preliminary 

iridectomy 
Mo iridectomy . . 



With iridectomy 
No iridectomy . . 
With iridectomy 

No iridectomy . . 



Usual operation. 
.No iridectomy 



With iridectomy 



No iridectomy . . 

With iridectomy 
No iridectomy . . 



With iridectomy 
No iridectomy . . 



With iridectomy 
After preliminary 

iridectomy 
No iridectomy . . 



Complications 

at time 
of operation. 



None 

)> 

5) 

)) 

>} 

)> 

}) 

>> 

)J 

)) 

■)> * ' 

Soft matter left 
Good 



Hosted by GOOgle 



1891] 



RESULTS OP CATARACT EXTRACTION. 



173 



Secondary 
complications. 



Immediate 
result. 



Remote 
result. 



Secondary 
operations. 



Complica- 
tions after 
secondary 
operations. 



Result 
after 2nd 
operation. 



Remarks. 



None 

Prolapse of iris 

None 

,j ........ 

Prolapse of iris 

None 

Iritis 

Prolapse of iris. 

Suppuration 
None 

Prolapse of iris. 
Some iritis 

None 

jj 

Iris caught in 

wound 
None 

)> 

>j 

K. striata. 

None 

Prolapse of iris 

Iritis . . . 

Prolapse of iris 

None 

jj ........ 

Iritis . . 



6/60 
6/60 

6/18 



6/60 
3/60 
P.L. 

6/6 J. 1 



6/18 
2/60 



6/60 

6/9 

6/18 

6/9 



6/6 J. 1 

6/18 
4/60 
6/12 

6/18 

6/60 ' 



6/9 
6/18 



1/60 
6/18 



6/18 
6/18 

6/9 

6/9 J. 1 



6/18 J. 8 



6/12 

6/24 



6/6 
1/60 



6/6 J. 1 

6/6 J. 1 
6/18 J. 4 



6/24 
6/36 
6/6 J. 1 

6/12 
3/60 
6/9 J. 1 



6/18 



6/18 



Iridectomy 
for pro- 



Needling 



Iridectomy 
for pro- 
lapse 

Needling 
Excision 



Needling 
Iridectomy 
for pro- 
lapse 

Needling 



Needling 



Iridectomy 
for pro- 
lapse. 
Needling 

Iris re- 
placed. 

Iridectomy 
for pro- 
lapse 

Needling 



Prolapse of 
iris. Vitre- 
ous lost 



6/9 J. 4 



6/12 J. 2 



J. 1 



6/9 J. 1 



J. 1 



6/24 



6/6 J. 1 



6/6 



6/6 J. 1 



Lens matter and 
blood still present. 



Primary suppura- 
tion. 



No. 186. 



No. 682. 



Hosted by XjOOQIQ. 



174 



ON THE IMMEDIATE AND REMOTE 



[1891-1892 



**! 








R. 


4J OD 

*Ph"5d 


Eye. 


A.g6. 


Sex. 


or 


CO CD 








L 













Condition 
of eye. 



Condition 
of patient. 



Operation. 



Complications 

at time 
of operation. 



47 


1514 


1 


61 


F. 


R, 


48 


1530 


1 


75 


F. 


R. 


49 


1556 


1 


72 


F. 


R. 


50 


1622 


2 


76 


M. 


R. 


51 


1688 


2 


53 


F. 


L. 


52 


1709 


1 


59 


P. 


R. 


53 


1751 


1 


70 


M. 


L. 



Good , 



Glaucomatous 
Good ...... 



1 


108 


1 


54 


F. 


R. 


2 


162 


1 


55 


F. 


R. 


3 


391 


1 


75 


F. 


R. 


4 


456 


'2 


45 


M. 


R, 


5 


487 


1 


5G 


F. 


R. 


6 


537 


1 


62 


M. 


L. 


7 


541 


1 


67 


M. 


R. 


8 


570 


1 


65 


M. 


L. 


9 


574 


2 


66 


F. 


R. 


10 


597 


1 


72 


F. 


R. 


11 


635 


2 


59 


F. 


R. 


12 


655 


2 


65 


F. 


R. 


13 


656 


1 


69 


F. 


L. 


14 


713 


1 


73 


F. 


R. 


15 


714 


1 


70 


F. 


R. 


16 


902 


1 


57 


M. 


R. 


17 


904 


2 


76 


F. 


R. 


18 


945 


1 


72 


F. 


R. 


19 


955 


1 


68 


M. 


L. 


20 


979 


1 


70 


F. 


R. 



G-ood 



Nystagmus . 



Good. 



Epiphora 
Good . . . 



Good . . , 
)> • • 

>> • • 

j, • • . 
,, . . . 

Good . . 

Diabetes 
Good . . . 



No iridectomy 



With iridectomy 



No iridectomy . . 
With iridectomy 



Diabetes, 
Good ... 



Conjunctival flap. 

No iridectomy. 

Capsule opened 

with cystotome 
After preliminary 

iridectomy 
With iridectomy 

•>■> jj 

No iridectomy . , 
After preliminary 

iridectomy 
With iridectomy 
No iridectomy. . . 
With iridectomy 
No iridectomy. . . 



With iridectomy 
No iridectomy . . 

With iridectomy 
No iridectomy. . . 



With iridectomy 



Good 

jj ......... 

j) ♦ 

)5 .... 

None 

jj 

n 

Tris buttonholed 
None 



Tris buttonholed 
None 



Hosted by GOOgle 



1891-1892] 



RESULTS OP CATARACT EXTRACTION. 



175 



Secondary 
complications. 



Immediate 
result. 



Remote 
result. 



Secondary 
operations. 



Complica- 
tions after 

secondary 
operations. 



Result 
after 2nd 
operation. 



Remarks. 



P.S 

Iritis 

Prolapse of iris 

Iritis 

None 

None 

Iritis and P. S. 
None 

Iritis K. P. ' 
Hypopyon 

Prolapse of 
iris. Iritis 



None 

J, ....... 

Iris caught in 

wound 
None 



6/9 J. 1 
4/60 J. 16 



Hand- 
movement 

6/24" 
6/24 



4/60 J. 16 
3/60 



6/a J. 1 

1/60 



Needling 

Needling 

Iridectomy 

for pro 



Iridotomy 
Needling 
Needling 



Eye_ 
shrinking 



6/18 J. 2 
6/9 J. 4 
6/18 



P.L. 

6/6 J. 1 
6/18 



No. 1052. 



2/60 



6/12 

6/9 J. 6 

6/9 
6/12 
Hand- 
moyement 
6/18 J. 6 

6/36 ' 
6,16 

6/12 

1/60 



6/24 
6/24 

6/18 
6/24 

6/60 
6/36 
6/36 





Needling 




6/12 J. 1 


6/6 J. 1 








2/60 








6/6 J. 1 
6/6 J. 1 
6/18 
6/6 J. 1 


Needling 




6/6 J. 1 


•• 


G-. cautery 


Hyphema 






1. Iridec- 
tomy for 
prolapse 

2. Scleral 


Glaucoma 


1/60 




puncture 
3. Iridec- 






6/18 J. 1 
6/12 

6/6 J. 1 

6/9 


tomy 
4. Needling 

Capsule 
extraction 


•• 


6/9 J. 4 


616 J. 1 
6/9 J. 6 









No. 655 (year 1891) . 



No. 452 (year 1891). 

No. 556 (year 1891). 
Senile dementia. 



No. 706 (year 1891). 



Hosted by GoOgle 



176 



ON THE IMMEDIATE AND REMOTE 



[1892-1893 



to © 



Eye. 



Age. 



Sex. 



Condition 
of eye. 



Condition 
of patient. 



Operation. 



Complications 

at time 
of operation. 



21 

22 



23 

24 



25 
26 



27 

28 
29 



30 



31 
32 



33 
34 
35 

36 



980 
1041 



1059 
1079 

1152 
1207 



1483 
1490 
1536 



1561 

1569 
1611 



1659 

1747 
1785 

1815 



72 F. 
62 F. 



61 M. 
80 M. 



M. 

M. 
F. 



L. Epiphora. 

Pterygium 
L. Good ' 



90 
202 


1 
1 


51 
62 


F. 
F. 


R. 
R. 



G-ood , 



Good , 



Albumin- 
uria. 
Rheumatic 



With iridectomy 

Usual operation. 
No iridectomy 



With iridectomy 
No iridectomy. . . 



After preliminary 
iridectomy 

No iridectomy. 
Hoolf- extrac- 
tion 

No iridectomy. . . 



With 



irid 



No 
With 

No 



irid 



iridectomy 



ectomy. . . 

j> • • • 

iridectomy 

ectomy . . . 



None 

,, ....... 

)> 

Vitreous lost , 
None 

Yitreous lost. 
None 



Yitreous 
opacities 



Rheumatic 



Good , 



Conjunctival flap, 
No iridectomy. 
Capsule opened 
with leys to tome 

Usual operation . 



None - 



Hosted by-GOQgk_ 



1892-1893] 



RESULTS OF CATARACT EXTRACTION. 



177 



Secondary 
complications. 



Immediate 
result. 



Eemote 
result. 



Secondary 
operations. 



Complica- 
tions after 
secondary 
operations. 



Besult 
after 2nd 
operation. 



Remarks. 



None 



Sere re iritis. 
Prolapse of 
iris. Blocked 
pupil 



Prolapse of iris 



None 

K. striata T.- 



None 

K. striata 
Prolapse of iris 
Hypopj on 



Prolapse of iris. 
Suppuration 

None 

Prolapse of iris 



None 



Prolapse of iris 



6/36 

Hand- 
movement 



6/60 
6/12 J. 4 



6/12 
4/60 



6/9 
6/24 
No P. L. 



; J. 10 



6/36 



6/9 J. 1 



6/12 J. 6 

6/9 J. 1 

6/24 J. 12 

6/9 J. 1 



l.G-.cautery 

2. Extrac- 
tion of 
capsule 

3. Iridec- 
tomy for 
prolapse 

Iridectomy 
for pro • 



6/18 J. 2 



5/60 J. 16 
6/18 

Fingers at 6/36 J. 8 
6" 



Iridectomy 
for pro 
lapse 



l.G-.cautery 
2. Excision 

Gr. cautery 
to pro- 
lapse 



Needling 

Iridectomy 
for pro- 
lapse 



Hand- 
rnovement 



6/9 J. 1 



amount 

of vitreous 

lost. 

Iritis. 



6/9 J. 1 

6/6 J. 1 
616 J. 1 



No. 597 (year 1892). 



Numerous vitreous 
opacities. 

No. 1079 (year 1892). 



None 



6/36 J. 19 



6/12 J. 4 



6/12 J. 6 



6/6 J. 1 



Hosted by-GOOgle 



178 



ON THE IMMEDIATE AND REMOTE 



[1893 



S3 _ 











R. 


G.'Sb 


Eye. 


Age. 


Sex. 


or 
L. 



Condition 
of eye. 



Condition 
of patient. 



Operation. 



Complications 

at time 
of operation. 



4 

5 

6 

7 
8 

9 

10 
11 
12 
13 

14 
15 
16 



17 
18 
19 

20 

21 
22 

23 



24 

25 

26 

27 

28 



203 

28 i 

324 

507 

591 
618 

634 

650 

787 
786 
826 

870 

959 

1062 



1144 
1157 
1171 

1684 

1685 

1728 

1741 



1744 
1766 
1838 

1946 
1960 



64 
63 
75 

65 

66 
65 

63 



F. R. Q-ood Good Usual operation 



L. 



Ch. conjunc- 
tivitis 
Good 



Glaucoma . 



Good 

Lac. obst. . 

Good 



Ch. conjunc- 
tivitis 

Ch. conjunc- 
tivitis 

Good 



Ch. conjunc- 
tivitis 
Good ...... 



Diabetic. 
Good .. . 



Albuminuria 

diabetes 
None 



Rheumatic 

fever 
Good 



Gouty, un- 
steady 
Good 



After preliminary 

iridectomy 
Iridectomy after 

extraction 
No iridectomy . . 



With iridectomy 

No iridectomy . . 
With iridectomy 



No iridectomy . . 
After preliminary 

iridectomy. 

Hook extraction 
With iridectomy 



Previous iridec- 
tomy 
With iridectomy 



After preliminary 

iridectomy 
Usual operation. 

With iridectomy 
With iridectomy 



Iridectomy, after 
extraction 



None 

>> 

j) 

j) 

>> • • * • 

)> 

Soft matter left 
None 

jj 

Vitreous lost. . 

None 



Hosted 



_ 



Google 



1893] 



RESULTS OF CATARACT EXTRACTION. 



179 



Secondary 
complications. 



Immediate 
result. 



Remote 
result. 



Secondary 
operations. 



Complica- 
tions after 
secondary 
operations. 



Prolapse of iris 
Iritis 

Pupil drawn 

up 
None 



Iritis 



Iritis 

Purulent iritis. 

Pupil drawn 

up 
None 



6/60 J. 16 

6/24 J. 8 

5/60 J. 14 

6/12 J. 4 

6/12 J. 4 
P.L. 

6/24 J. 4 



6/12 J. 1 



6/6 J. 1 



6/6 J. 1 
Hand- 
movement 
6/12 J. 1 



6/12 J. 4 6/9 J. 1 

2/60 J. 20 3/60 

6 ; 36 J. 12 6/24 

6/24 J. ]() 624 J. 12 



Iridectomy 
for pro 
lapse 



6/24J. 12 
6 9 J. 1 

6/24 



K. striata 



None . 



Prolapse of iris 



None , 



(y!6 J. 1 
6/6 J . 1 

6/24 



6/60 J. 12 6/12 J. 6 

6/12 J. 2 

Fingers at i 6/60 J. 15 

18" | 

5/60 J. 16 j 6/12 J". 6 

6/36 J. 12 6/6 J. 1 
4/60 J. 15 6 6 J. 1 



Iridectomy 



Needling . 
Needling . 



Needling 



Prolapse of 
angle of co- 
loboma 



6/24 J. 8 

6/36 J. 14 
6/36 J. 15 

6/24 J. 15 

6/12 J. 4 
6/12 J. 6 



t/24 J. 8 

6/12 J. 2 
6/18 J. 12 
6/18 J. 14 



6/12 J. 1 



1. Iridecto 
my for 
prolapse. 

2. Needl- 



Iridectomy 
for pro- 
lapse 



Result 
after 2nd 
operation . 



Remarks. 



6/36 J. 15 



6/12 
6<6 J. 1 



6/9 J. 1 



6/12 J. 6 



Slightly cystoid ecar 
at inner angle of 
coloboma. 



No. 381 (year 1890). 
No. 487 (year 1892). 



No. 985 (year 1890). 



No. 787 (year 1893). 

Vitreous opacities 

and choroiditis. 



Vitreous opacities. 
R. eye, No. 1514 
(year 1891) . 



No. 273 (year 189]). 



VOL. XIV. 



Hosted by G00gle 



180 



ON THE IMMEDIATE AND REMOTE 



[1889 



8 


r> 
n 

12 



13 



14 
15 



16 

17 
18 
19 



Is JS 








R, 


■~£ Is 


Eye. 


Age. 


Sex. 


or 


co o 








L. 


£^ 










i-H 











Condition 
of eye. 



520 


1 


593 


1 


976 


1 


1087 


2 


1133 


1 


1258 


1 


1323 


1 


13G7 


1 


146o 


1 


1471 


2 


1591 


1 


1606 


1 


1694 


2 


1909 


1 



2155 



2160 

2225 

1S86 
2264 



65 



2 57 F. 



68 



F. 


R, 


F. 


L. 


M. 


L. 


F. 


R. 


M. 


L. 


F. 


R. 


M. 


L. 


F 


R, 


F. 


R. 


M. 


R. 


M. 


R. 


M. 


L. 


M. 


R. 


M. 


R. 


F. 


L. 


F. 


R. 


M. 


L. 


F. 


L. 


F. 


L. 



Good 

n « • • . 

Projection 

doubtful 

G-ood .... 



Disseminatet 
choroiditis 

Lens dis- 
located. 
Vitreous 
opacities 

G-ood 



Condition 
of patient. 



Diabetes. . , 



G-ood , 



Not noted . 



G-ood 



Neurotic , 
Good 



Operation. 



Complications 
at time of 
operation. 



Section at corneo- 
scleral junction. 
After prelimin- 
ary iridectomy 
capsulotomy 
with cystotome 

Peripheral cap- 
sulotomy 

Usual operation 

Scoop extraction 



Usual operation 



>5 )) 



! No iridectomy . 
Usual operation 



None 

,) ......... 

Iris cut with 
kni f e 

Nearly £ vitre- 
ous lost 

None . .• 

3) • ♦ • • 

jj • • • • 

>J 

Lens movable 
and extruded 
by patient 
squeezing 

Soft matter re- 
mained 

None 



Hosted by 



Google 



1880] 



RESULTS OF CATARACT EXTRACTION. 



181 



Secondary I Immediate | Remote 
complications. I result, j result. 



Iritis 



None 

Slight iritis . , . 

Much mem- 
brane in pupil 

Suppuration .. 

None 



Iritis and P. S. 
N one 



J. 10- 



6/60 



Secondary 
operations. 



Complica- 
tions after 
secondary 

operations 



6/60 J. 12 



Needling 



Noe 



Post, synechia 1 ! 
None 



Slight iritis. 

Iritis and P. S. 
Non „> 



Fingers at ! f/24 J. 10 
18 7 ' 



6/60 J. 10 j 6/9 J. 1 

4/60 i 6/12 J. 4 

6/60 i 

6/36 J. 12 6/24 J. 1 
6/60 J. 18 i 6/18 J. 1 
1/60 J. 2U ; 



Excision 



J. 20 



6/36 



J. 12 ; 6/12 J. 1 



6/36 J. 12 6/12 J". 1 
6/60 J. 15 | 6/y J. 1 



6/60 J. 15 1/60 



6/24 J". 1 
6/60 J. 16 
6/18 J. 12 



6/24 J. 12 



| 
Needling None 



Needling 



Result 
after 2nd 
operation. 



Remarks. 



6/12 J. 4 



6/ r J. i 

6/12 J. 1 



L. did well. R, ? 
vitreous opacities 
and capsule. 



See No. 2155. 



L. did well. 



Anesthetic chloro* 
form. 



L. lost from glau- 
coma after couch- 
ing by 'the Indian 
oculists." 

1st did well. See 
No. 1258. 



1 



N 2 



Jtosted by GOOgk^ 



182 



ON THE IMMEDIATE AND REMOTE 



[1890 



Eye A.ge 



r 



10 

li 



12 

13 



14 
15 



16 



17 

1M 



39 



222 
245 

268 
269 

309 



426 

417 
465 



535 
747 



791 
1005 



1063 



1334 
1306 



60 



80 



69 



64 



2 ! 67 



2 56 



1318 2 69 



1319 



F. 



M. 



B. 



Condition 
of eye. 



Condition 
of patient. 



Operation. 



Complications 

at time 
of operation. 



Good , 



Projection 
not good 



Go »d 



Post, syne- 
chiae 



Good 



Good 

Unsteady . . 
Good 

Unsteady 

Good 

Unsteady. 
Good ./.. 

Rheumatic 
Good .... 



Corneo- scleral 
section after 
preliminary iri- 
dectomy. Cap- 
sule opened 
with cystotome 

Usual operation . 

Nc iridectomy 
After preliminary 
iridectomy 



No iridectomy . . 
Usual operation . 

No iridectomy . . 
Usual operation 

No iridectomy . . 



Hook and scDop 
extraction 



Usual operation . 

Attempt to re- 
move opaque 
capsule with 
forceps 



Some soft matte) 
left 



None 

Soft matter left 
None 

>? ■ * ■ 

Yery bad pa- 
tient 

None 



Hosted by 



Google 



189!)] 


RESULTS OF 


CATARACT EXTRACTION. 


183 




Secondary 
complications. 


Immediate 
result. 


Remote 
result. 


Secondary 
operations 


Cornplica- 

1 lions after 

secondary 


Result 
after 2nd 
operation. 


Hemarks. 








movement 




| operations. 




Purulent iritis 


Hand 


Paracen- 




] 




30 days after 






tesis 


! 








extraction 
















None 


6/36 J. 12 


6/9 J. 1 


! 




R. did well. 




„ 


6/18 J. 4 


6/18 


Needling 


None .... 


6/6 ir. i 


L. did well. 




Severe iritis. . . 


6/60 J. 14 


6/9 












None 


6/24 J. 10 


6/6 J. 1 


•• 




• • 


R, did well. 




Serous cyclitis 


Hand- 


Hand- 








Two months later 




and K. punc- 


movement 


movement 








sympathetic ophth. 




tata 












in the R. 




None 


1/60 
6/60 










L. lost after cata- 
ract extraction 
elsewhere. No 
note as to why 
vision was so bad 
in R. 




>5 


6/6 J. 1 


6/36 


Needling 1 


•• 


6\6 J". 1 


L. suppurated and 
was excised after 
cataract extraction 




,, 


6/6 J. 1 


6/6 J. 1 












Prolapse of iris 


6/12 


• • 


Iridectomy 
for pro- 
lapse 










Iritis 


61*6 J. 12 


6/18 J. 6 








» 




None 


6/12 J. 12 


6/18 j . 12 


Needling 




6/9 J. 1 


R. did well." No 
note of Y. (No. 
1773, year 1S89). 




)> 


6/24 J. 12 


6/24 J. 8 


Needling 


None .... 


6/9 J. 1 


R. did* well (No. 
1635, year 1889). 




Post, synechias 


6/60 


6/24 


Needling 


,, 


6/24 


L. did fairly well. 
(No. 1606, vear 
1889.) R. 'has 
vitreous opacities. 




') j> 


5/60 J. 14 


Pingers at 
6" 


Needling 




6/60 J. 14 


R. lost irorn inflam- 
mation in child- 
hood. Extraction 
done under ether 
and chloroform. 




" " 


6/12 


6/6 J". 1 


- 










K. striata 


6/36 


6/9 J. 1 











Hosted by 



Google 



184 



ON THE IMMEDIATE AND REMOTE 



[1890-1891 



o 



o3 ao 



Wye. 



Age.! Sex. 



Condition 
of eye. 



Condition 
of patient. 



Operation. 



Complications 

at time 
of operation. 



19 

20 



21 



22 

23 

24 
25 



26 
27 



2S 



29 



1377 
1406 



1432 



1526 

1547 
1628 
1724 



1765 

1800 



1879 



1880 



67 



1 67 



30 


1882 


1 


76 


31 


1925 


1 


78 


32 


1335 


1 


65 



M. 



Stf. 



M. 



M. 



R. 



Good . 



Ch. conjunc- 
tivitis, mu- 
cocele 

Good 



Good , 



Glaucoma- | 
to us; field i 
contracted | 

Good ; 



I Cough 
Good . , 



Usual operation . 



None 

Difficulty in re- 
moving lens. 
A bead of 
vitreous lost. 



| Some soft matter 

i left 

! None 



No iridectomy . 
Usual operation . 



Scoop extraction 



Usual operation . 



fris transfixed by 
knife. Prelimi- 
nary iridectomy 
had not been 
done 

Usual operation . 



Violent cough 
during opera 
tion. A little 
vitreous lost 

None 



Large lens re- j 
moved with j 
hook with : 

difficulty j 

None '■ 



15 



2 22 

3 ' 269 



66 



M. 


R. 


Good .... 


Good 


Section at corneo 
scleral junction. 
No conjunctival 
nap. i'relini. 
iridecromy. 


None 












Capsule opened 


1 








• 


with cystotome 




F. 


E. 


Hyper mature 
cataract 


" 


Usual operation 
1 


Iris transfixed . | 


F. 


L 


Incomplete 


Very 


» » 


Spasmodic en- j 






cataract 


unsteady 




ti opion 





Hosted by GOOgle 



J 890-1891] 



RESULTS OF CATARACT EXTRACTION. 



185 



■ Secondary 
complications. 



Immediate 
result. 



Remote 
result. 



Secondary 
operations. 



Complica- 
tions alter 
secondary 
operations. 



Result 
after 2nd 
operation. 



K. striata. . . . 
None , 



Iritis 
None . 



Iritis 



| None 



6/60 I 

Counts ! 6/60 
fingers 



Needling : None , 



Plastic iritis . . 
Slight iritis. . , 



I 6/18 
I 4/60 



4/60 
1/60 



4/60 



6/9 J. 1 | 

6/60 j Needling 

6/60 Needling 



6/36 J. 12 



6/24 



4/60 J. 14 
6/18 



6/60 



6/60 

6/60 



6/18 



Needling 



None . 
None 



Needling 



Needling 
Needling 



Needling 



None 



6/36 



Gj6 J. 1 
6/9 J. 1 

6/6 J. 1 



6/9 



6/12 J. 4 
6,9 J. 1 



6/6 J. 1 



Remarks 



Vitreous opacities. 



No further note. 



L. did well. 

R. needled did well. 

R. operated upon 

elsewhere. l)id 

not do well. 

Extracted under 
ether and chloro- 
form. 



Later result V. = 
hand-movement. 
Vascular keratitis 
and vitreous opa- 
cities. 





None 


6/6 J. 1 


6/60 


Needling 


None 


6/6 J. 1 


L. did well after 
extraction three 
years ago. 




,, 


6/36 


3/60 J". 15 


Needling 


_y'~ 


6/9 


Yitrcous opacities. 




Much iritis . . 


6/36 


6/60 


Needling 


Irido- 
cyclitis 


1/60 


R. lost after ex- 
traction elsewhere 



Hosted by GOOgle 



186 



ON THE IMMEDIATE AND REMOTE 



[189l! 











E. 


.~£ ^ 


liye. 


Age. 


Sex. 


or 










L. 


W^ 











Condition 
of eye. 



5 


270 
430 


1 

1 


66 
56 


F. 
F. 


L. 
L. 


6 


453 


1 


69 


F. 


L. 


7 
8 
9 


707 
746 
647 


1 
1 
1 


69 
75 
65 


F. 
F. 
F. 


L 
E. 
E. 


10 


822 


2 


64 


F. 


L. 


11 
12 
13 
14 
15 


843 
86S 
922 
989 
1079 


2 
1 
1 
1 
1 


73 

78 
64 
61 
52 


F. 
M. 
F. 
M. 
F. 


L. 
E. 
E. 
L. 
L. 


16 
17 


1307 
1516 


1 
1 


66 
66 


M. 
F. 


L. 
E. 


18 


1583 


1 


68 


F. 


L. 


19 


1626 


2 


67 


F. 


L. 


20 


1705a 


1 


68 


M. 


E. 


21 


1707 


2 


47 


M. 


E. 


22 
23 


1727 
1851 


1 

2 


50 
76 


M. 

F. 


L. 
L. 


24 


1863 


2 


61 


M. 


L. 


25 


747 


1 


65 


F. 


E. 



G-ood 

Old iritis . . 



Good. 



Hypermature 
cataract 
Good .... 



Hypermature 
cataract 



Good. 



Incomplete 
cataract 



Good, 



Brown cata- 
ract 



Condition 
of patient. 



Good 

Unsteady , , 

Good 

j, ...... 

)) 

J5 

3) 

53 

Unsteady . . 
Good 



Operation. 



Co in plications 

at time 
of operation. 



Usual operation . None . 



No iridectomy 
Hook extraction 

Usual operation. 

Iridectomy at 
time of extrac- 
tion 

Usual operation . 



Soft matter left 

33 33 



None. 



Soft matter left 

Flaccid cornea . 
None . . . „ 



Iris fell before 
knife 

Soft matter left 



Small section 

and large lens 

Soft matter left 



Yitreous lost . . 



None 



4 



Hosted by GOOgle 



1891] 



RESULTS OF CATARACT EXTRACTION. 



187 













Complica- 








Secondary 


Immediate 


Remote 


Secondary 


tions after 


after 2nd 


Remarks. 




complications. 


result. 


result. 


operations. 


secondary 
operations. 


operation. 






Iritis and P.S. 


6/60 


3/60 


Needling 


None .... 


6/12 J. 6 






Iritis 


3/60 


6/24 


Capsule 
extraction 


>) 


6/6 J. 1 






Ectropion 


6/18 J. 1 














K.S. 
















None 


1/60 
4/60 

6/9 J. 1 


6/36 


„ „ 




6/6 J. 1 


R. did well after 
extraction three 
years ago. 




)) 


6/60 




•• 






R. No. 22. 




" 


6/60 


2/60 J. 19 


Needling 




6/18 J. 12 






Post, syn 


2/60 


6/60 


Needling *<r 




6/60 


Vitreous opacities. 




None 


6/36 
6/36 


6/60 


Needling 




6/24 


Old disseminated 
choroiditis. 




Spasmodic en- 


6/36 


6/36 


Needling 


None .... 


6/6 J. 1 






tropion 
















None 


Hand- 
movement 


3/60 


Needling 


.. 


6/18 






Suppurative 




3/60 


Needling 


Severe 


2/60 


R.., No. 520 (year 




iritis 








iritis 




1889). 




K. striata. . . . 


1/60 


P.L 






•• 


Large leucoma ad- 
herens ; ? cause. 




Secondary pro- 


6/24 




Iridectomy 






L. did well after 




lapse 






for pro- 
lapse 






extraction. 




None 


6/60 


6/36 


Needling 




6/9 J. 1 






Post, syn 


6/9 


6/18 J. 2 


Needling 




6/6 J. 1 


R. did well after 
extraction six 
years ago. 




Iritis 


2/60 


6/60 


Needling 




6/6 J. 1 


R. did well after 
extraction, No. 
1335 (year 1890). 
L. much capsule 
left. 




None 


4/60 


6/60 


Needling 


* • 


6/6 J. 1 





Hosted by 



Google 



188 



ON THE IMMEDIATE AND REMOTE 



[1892 



o 











R. 


-4J OJ 

"£/Sb 


Wye. 


Age. 


Sex. 


or 

r, 


Vj <U 



















Condition 
of eye. 



CoDdition 
of patient. 



Operation. 



Complications 

at time 
of operation. 



66 



10 



13 

14 

15 

16 
17 



18 
19 



20 



101 
111 
195 

377 

573 
692 

863 

954 

743 



11 ! 757 

12 762 



783 

1080 

1299 
1300 
1349 



126 
1364 



1440 



1 


69 


M. 


L. 


1 


71 


M. 


L. 


1 


67 


F. 


R. 


1 


50 


F. 


L. 


2 


69 


M. 


L. 


1 


63 


i<V 


L. 


1 


39 


F. 


R. 


1 


50 


M. 


R. 


1 


67 


F. 


R. 


2 


68 


F. 


R. 


2 


66 


F. 


L. 


1 


43 


M. 


L. 


2 


63 


Jb\ 


L. 


1 


63 


M. 


R. 


1 


52 


F. 


L. 


1 


6i 


Jj\ 


K. 


1 


80 


F. 


R. 


1 


60 


iVl. 


L. 


2 


71 


M. 


L. 


2 


63 


F. 


L. 



Good . . . 

JJ • • 

,, ... 

,, ... 

Myopic . 
G-ood . . . 

j, . • . 
,, . . . 

Sjirunk*jn 
lens 

Good 



Good 

Syphilitic 
aood 
Diabetic. , 
Good . . . . 

,, . . . . 

,, • . . . 
,, . . . . 

,, . . . . 

Good . . . . 



Section at corneo- 
scleral junction. 
No conjunctival 
nap. After pre- 
liminary iridec- 
tomy. Capsule 
opened with 
cystotome 

Usual operation . 



No iridectomy . , 
Usual operation 



None 



No iridectomy . 
Usual operation 



Iridectomy done 
at time of ex- 
traction 
Usual operation . 
Capsule removed 
with forceps and 
lens with scoop 
after prelim i nary 
iridectomy 
Usual operation, 
but small con- 
junctival flap. 



Movable lens . . 
Soft matter left 

None 

Very sticky soft 
matter 



Prolapse of 

vitreous 
Soft lens matter 

left 
None 

Soft matter left 

None 

Vitreous pre- 
sented 
Cornea flaccid. . 

None 

Vitreous lobt. . . 

None 



Hosted by 



Google 



1892] 



RESULTS OF CATARACT EXTRACTION'. 



189 



Secondaiy 
complications. 



Immediate 
result. 



Remote 
result. 



Secondary 
operations. 



Complica- 
tions after 
secondary 
operations. 



Result 
after 2nd 
operation. 



Remarks. 



None , 



Iritis and P.S. 
None 



Slight iritis . . . 
[ris adherent 

to scar 
Iritis and P.S. 



None . 
Tritis . 

None 



Prolapse of 
capsule. Iritis 



Iritis 



6/24 



6/24 
6/24 
6/9 
6/60 

6/18 
6/12 

2/60 

1/60 

6/24 

6/60 
3/60 

6/12 
4/60 



6/9 J. 4 



„ 6/36 J". 10 

K. striata Qj6o J. 16 

None J 6/60 J. 1© 



6 36 
6/60 J. 12 



1/60 



6/9 J. 1 

6/24 

6/60 

6/18 

6/12 J. 1 

6/24 
6/12 J. 6 

3/60 J. 15 



6/18 J. 2 

6/18 J. 4 
6/12 J. 4 



4/60 
3/60 J". 20 



Needling 
Needling 
Needling 



Needling 



Capsule 

prolapsed. 

removed 



Needling 



Needling 



6/18 

6/9 J. 1 
6/6 J. 1 



6/36 



Vitreous 
lo&t 



6/12 



■>/18 J. 2 



Vitreous opacities. 



R., No. 1705(a) 
(year 1891). 



L., No. 270 (year 
1891). R.,vitreous 
opacities. 

R., No. 747 (year 
1891). Capsule. 

Much capsule. 



R., No. 268 (year 
1890). 



R., No. 1880 (year 
1890). ^ Vascular 
keratitis and 

vitreous opacities. 

R., No. 111. 



Hosted by G00gle 



190 



ON THE IMMEDIATE AND REMOTE 



[1892-1893 



& 



, 5-! 








E. 


P-i'bJO 
CO a* 


Eye. 


Age. 


Sex. 


or 
L 


^ 











Condition 
of eye. 



Condition 
of patient. 



Operation. 



Complications 

at time 
of operation. 



21 


1550 


1 


39 


M. 


E. 


22 


1510 


1 


56 


F. 


L. 


23 


1663 


1 


70 


F. 


L. 


24 


1741 


2 


65 


F. 


L. 


25 


1742 


1 


66 


F. 


L. 


26 


1764 


1 


67 


M. 


L. 


27 


1830 


1 


67 


F. 


E. 


.28 


1946 


1 


77 


F. 


E. 



Good 



Post. syn. 
after pre- 
liminary 
iridectomy 
followed by 
iritis 

G-ood 



Good , 



Lens extracted 
without iridec- 
tomy, but iris 
was so bruised 
it had to be 
clone 

Usual operation . 



Vitreous pre- 
sented 



None 

Soft matter left 



None , 



Small section 
lens difficult to 
deliver 

Vitreous pre- 
sented 

None 



1 


46 


1 


71 


M. 


E. 


2 


49 


1 


64 


F. 


E. 


3 


103 


L 


63 


F. 


E. 


4 


151 


2 


65 


M. 


L. 


5 


258 


1 


74 


F. 


E. 


6 


428 


1 


67 


M. 


L. 


7 


593 


1 


66 


M. 


L. 


8 


790 


1 


68 


F. 


E. 


9 


891 


1 


75 


M. 


E. 


10 


910 


1 


70 


F. 


E. 


11 


1039 


1 


59 


F. 


E. 



Old iritis 
and post 
synechia 



Good , 



Good . . , . 

,j .... 
,, . . . . 

Cough. . . . 
Good 
Unsteady 
Good 

Asthmatic 
Good .... 



Section at corneo- 
scleral margin 
after prelimi- 
nary iridectomy. 
Capsule opened 
with cystotome 

Usual operation . 



Difficult to de- 
liver. Soft 
matter left 



Soft matter left 



Vitreous lost . . . 
None ......... 

Soft matter left 
None 



Hosted by 



Google 



1892-1893J 



RESULTS OF CATARACT EXTRACTION. 



191 



Secondary 
complications. 



Immediate Remote 
result, i result. 



Secondary 
operations. 



Complica- 
tions after 
secondary 
operations. 



Result 
after 2nd 
operation. 



None . 



Atropine irri- 
tation 



None , 



6/24 



6/12 

Fingers at 
6" 



3/36 

4/60 

6/60 J. 14 

6/36 
6/60 J. 10 



6/60 J. 15 Needling 



6/6 J. 1 
6/24 J. 8 



J. 14 



6/24 J. 12 

6/12 J. 6 
6/24 J. 6 



Capsule 
extraction 



Needling 
Needling 



None , 



6/24 J. 6 



6/12 J. 1 

6/6 J. 1 
6/9 J. 4 



Remarks. 



R M No. 1516 (year 
1891). 



Vitreous opacities. 
Membrane. 





Ectropion .... 


Hand- 
movement 


«• 


•• 


•• 


•• 


Lens matter present. 




None 


2/60 J. 19 


6/12 J". 1 












X. striata 


6/12 J. 2 


6/9 J. 1 












Iritis 


Hand- 
movement 




Needling , 






R. did well after ex- 
traction elsewhere. 
L M still a lot of lens 
matter. 




None 

3) ' ' * 


3/60 J. 19 
6/60 J. 15 
4/rtO J. 18 
6/18 J. 4 
6/36 J. 8 


6/9 J. 1 
6/18 J. 2 

6/12 J. 6 












Atropine irrit. 




.. 




.. 




Sight clest roved. 




Slow bleeding 
















and iridocy- 
















clitis 
















None 


6/36 J. 15 


6/12 J. 1 











Hosted by GOOgle 



192 



ON THE IMMEDIATE AND REMOTE 



[18.93-1889 











E. 


■43 CO 


Eye. 


Age 


Sex. 


or 


Oi o 








L. 


£* 











Condition 
of eye. 



Condition 
of patient. 



Operation. 



Complications 

at time 
of operation. 



12 


1362 


1 


74 


F. 


E. 


13 


1387 


2 


59 


F. 


E. 


14 


1402 


2 


67 


M. 


E. 


15 


14>7 


1 


6S 


F. 


E. 


16 


1665 


2 


55 


F. 


E. 


17 


1803 


2 


78 


F. 


E. 


18 


1882 


1 


81 


M. 


E. 


19 


1883 


1 


78 


M. 


E. 



G-ood . . 

5) • < 

Myopic 
G-ood . . 

Good . . 



Feeble . 



Good , 



Usual operation . 



Cough , j „ 

Feeble I 



None , 



Soft matter left. 



None 

Soft matter left 



None , 



Cornea yery 
flaccid 



None , 



10 
11 

12 
13 

14 

15 



92 


1 


58 


F. 


E. 


288 


2 


68 


F. 


L. 


320 


1 


60 


F. 


E. 


531 


1 


69 


M. 


E. 


558 


1 


58 


F. 


h. 


599 


1 


— 


F. 


E. 


681 


1 


64 


F, 


L. 


724 


2 


58 


F. 


L. 


725 


2 


74 


F. 


L. 


807 


1 


64 


F. 


E. 


809 


1 


70 


M. 


L. 


951 


1 


64 


M. 


L. 


1030 


1 


68 


F. 


L. 


1763 


1 


60 


M. 


E. ' 


1785 


1 


7J 


M. 


L, ! 



Good . 



Cough 
Good . 



Cough , 
Good . . 



Ch. bron- 
chitis 
Good 



Small conjunc- 
tival flap. Iri- 
dectomy. 
Caps ul otomy 
done with cys- 
totoine 

Peripheral cap- 
sulotorny 

After preliminary 
iridectomy 

)•> » ( 

Usual operation . 



Peripheral cap- 
sulotomy 



None - 



Some soft matter 
left 



None 

Soft matter left 

Soft matter 

scraped out 
None t 



Hosted by GOOgle 



1893-1889] 



RESULTS OF CATARACT EXTRACTION. 



193 



Secondary 
complications. 



Immediate 
result. 



Remote 
result. 



Secondary 
operations. 



Complica- 
tions after 

secondary 
operations. 



Result 

after 2nd 
operation. 



Remarks. 



Flap became 
folded ou it- 
self and 
wound gaped 
widely. 

None ..,,..... 



K. striata .. 



Severe- bron- 
chitis 

None 



1/60 J. 


16 


6/60 J. 


8 


2/60 




6/60 J. 
6/60 J. 


18 
19 


6/36 J. 


12 


6/60 J. 


15 


6/36 J. 


10 



6/18 J. 6 

6/24 J. 6 

6/1 2, T. 1 
6/12 J. 1 

6/18 J. 6 
6/60 J. 15 
6/12 J". 2 



Needling 



6/6 J. 1 



L. excised as a 
shrunken globe 
after a lime burn. 



L. eye, No. 438 
(year 1891). 

L. eje, No. 428. 
Anaesthetic ether. 

Vitreous opacities. 

L. eye, No. 1510 
(year 1892). 

L. did well after ex- 
traction nine years 
ago. 

Vitreous opacities. 
Central choroid- 
itis. 



None , 

Iritis and hy 
phseina 

Iritis 

None ....... 

jj 

Iritis 

None 

Keratitis striata 

Iritis 

None 



6/36 J. 10 



6/12 J. 
1/60 



4/60 J. 
6/60 J. 



6/60 



2/60 J. 

2/60 J. 

3/60 J. 

J. 

6/60 J. 
6/60 J. 



6/18 J. 1 



5/60 

6/60 J. 16 

6/18 J. 6 
6/9 

Fingers at 
6" 



6/12 3". 1 
6/18 

2/60 J> 10 
6/6 J. 1 
6/36 
6/24 J. 4 



16 6/60 J. 15 
12 6/18 ,T. 4 



Needling 
Needling 

Needling 

Para- 
centesis 

Needling 

Needling 
Needling 

Needling 
Needling 



None 6/6 J. 1 
Glaucoma 6/18 tT. 8 



None 



R. did welh 



Still soft matter 
present. 

R, did well, No. 92. 



6/60 ,L 12 

6/9 J. 1 
6/9 



6/13 ,L 4 

6/24 , Vitreous opacities, 



Hosted by 



Google 



194 



ON THE IMMEDIATE AND REAIOTE 



[1889-1890 



s-3 








E 












*P-i'5b 


Wye. 


Age. 


Sex. 


or 
T, 


C/J O 








O r^ 











Condition 
of eye. 



Condition 
of patient. 



Operation. 



Complications 

at time 
of operation. 



16 


1950 


1 


70 


M. 


L. 


17 


2088 


1 


17 


F. 


L. 


IS 


210 1 


1 


65 


F. 


E. 


19 


2152 


2 


66 


F. 


L. 


20 


2228 


1 


73 


M. 


K. 


21 


847 


1 


60 


F. 


E, 



Incomplete 
cataract 

Myopia ; all 
the family 
have cata- 
ract 

Good 

Dark 

coloured 

cataract 
G-ood 

aood 

J? * 

,, ...... 

,, ...... 

Fluid cortex 

G-ood ...... 

Myopic . . . 

Incomplete 

cataract 

Good , 

bine injec- 
tion and re- 
sults of sym- 
pathetic iritis. 
Cornea hazy. 



Good 

j, ...... 

33 

33 

aood 

Unsteady . . 
aood 



Peripheral cap- 
sulotomy 

Capsulotomy 
done across lens 
with cystotome 



None 

33 

None 

Yitreous lost 
None 



1 


34 


1 


48 


F. 


L. 


2 


97 


2 


70 


M. 


E. 


3 


384 


1 


70 


F. 


E. 


4 


525 


2 


48 


F. 


E. 


5 


552 


1 


66 


F. 


L. 


6 


628 


1 


64 


F. 


L 


7 


651 


2 


35 


F. 


E. 


8 


671 


2 


59 


F. 


L. 


9 


734 


1 


70 


M. 


E. 


10 


818 


1 


70 


M. 


E. 


11 


860 


1 


55 


F. 


L. 


12 


875 


2 


69 


M. 


E. 



Section at corneo- 
scleral junction. 
Iridectomy. 
Capsule opened 
with cystotome. 

Usual operation . 

Peripheral sec- 
tion of capsule. 

Usual operation . 



Peripheral sec- 
tion of capsule. 

Usual operation 



Cataract removed 
in its capsule 



Hosted by GOOgle 



1889-1890] 



RESULTS OF CATARACT EXTRACTION. 



195 













Complica- 








Secondary 


Immediate 


Remote 


Secondary 


tions after 


after 2nd 


Remarks. 




complications. 


result. 


result. 


operations. 


secondary 
operations. 


operation. 






None 




2/60 J. 14 


Needling 


None .... 


6/2 J< J. 8 






Mania 


3/60 J. 20 


•• 


•• 




•• 


Followed by acute 
mania for one day. 




None 

j> 


6/36 J. 10 
3/60 J. 19 
6/36 J. 12 


6/12 J. 1 
6/36 J. 16 
6/36 J. 16 






•• 


R. did well. 


1 


Grlaucorna .... 


6/24 J. 14 


6/12 


Iridectomy 
for glau- 
coma 




6/60 


Fundus changes. 
Syphilitic. 


\ 


None 


6/60 
6/60 


6/24 


Needling 


None 


6/3 J. 1 


L. did well. 




>j 


5/60 


Hand- 
movement 


1. Irido- 
tomy 

2. Needling 


Both fol- 
lowed by 
hypopyon 








Nodo 


6/24 


6/6 J. 1 


* * 






L. lost vitreous and 
Y. failed from 
vitreous opacities. 




Iritis 


5/60 


3/60 


L. Needling 

2. Sclero- " 

to my 


Grlaucorna 
and iritis 


6/60 


Later T. + 2. Disc 
cupped. 




None 

5> 


6/12 
6/36 


6/6 J". 1 
6/12 J. 1 




•• 




L. shrunken after 
cataract extraction 
elsewhere. 




„ 


6/60 


4/60 


Needling 


None 


6/9 J. 1 


R. did well. 




}y 


6/9 


6/60 


Needling 


„ 


6/6 jr. i 






Iritis 


Hnnd- 
moyement 


Hand- 
moyement 


Needling 


>) 


3/60 J. 14 


L. removed as a 
blind and sh runken 
globe. Much cap- 
sule and vitreous 
opacities. 




None 


6/9 J. 1 


6/6 J. 1 












N. 


further 


notes 






" 


L. extraction, 1888, 
followed by sym- 
pathetic in R. 








i 




Both eyes quieted 






; R. = 3/60 J. 12, 




VOL. XIV. 
















Hosted by GOOgle 



196 



ON THE IMMEDIATE AND REMOTE 



[1890-1891 



r— 1 <3 








R. 


"o,"bjD 


Eye. 


Age. 


Sex. 


or 
T, 


3 P3 










W^ 











13 
14 
15 

16 

17 



18 



Condition 
of eye. 



1113 
1133 
1141 

1289 
132S 



1336 



19 

20 


1340 
1438 


21 


1460 


22 


1535 


23 


1570 


24 


1690 


25 


1782 


26 


1784 


27 


1832 



Condition 
of patient. 



2 


69 


F. 


R, 


2 


71 


M. 


R. 


2 


69 


F. 


R. 


2 


70 


M. 


L. 


1 


71 


M. 


R. 


1 


67 


M. 


R. 


1 


56 


F. 


L. 


1 


72 


F 


R. 


1 


67 


M. 


R. 


1 


67 


M. 


R. 


1 


74 


F. 


L. 


1 


71 


F. 


R. 


2 


66 


M. 


R. 


1 


60 


M. 


R. 


1 


69 


M. 


R. 



Good 



Projection 
not good. 
Ch. ciliary 

blepharitis. 

Good ....... 



Myopia . . 
G-ood 



Good 

Good ...... 

Gouty 

Good 

,j ...... 

Eczema of 

face 
Good 



Operation. 



Complications 

at time 
of operation. 



Usual operation 



Lens removed 
without iridec- 
tomy. Iridec- 
tomy done, as 
iris would not 
go back. 

Usual operation . 



Peripheral sec- 
tion of capsule 
Usual operation . 



None 

5) 

>J ;> • • ■ 

Difficulty in de- 
livering. Yery 
large lens 

None 



Utter want of 
control on part 
of patient. 



None . 



19 


1 


57 


F. 


R. 


41 


1 


55 


F. 


L. 


70 


2 


60 


M. 


L. 


87 
335 
346 


1 
1 
1 


64 
61 

38 


F. 
F. 

F. 


R. 
L. 
R. 


397 


1 


70 


F. 


R. 



Good . 



Corneal ne- 
bulas 



Good , 



Zonular cata- 
ract 



Cough 



Good , 



Conjunctival flap. 
Iridectomy. 
Capsule opened 
with cystotome 

Usual operation . 



None . 



Hosted by G00gle 



1890-1891] 



RESULTS OF CATARACT EXTRACTION. 



197 





Secondary 
complications. 


Immediate 
result. 


Eemote 
result. 


Secondary 
operations. 


Complica- 
tions after 

secondary 
(Operations. 


Result 
after 2nd 
operation. 


Remarks. 


1 


None 

jj ........ 

>> 

None 

5) 

)> - 

)> * " 


6/9 J. 1 
6/60 

6/18 J. 10 

6/24 

6/18 

6/18 J. 1 

6/36 J. 4 
6/24 J. 10 
6/24 

6/18 
6/60 


6/24 
6/6 J. 1 
6/60 

6/24 
6/18 

6/24 J. 12 

6/6 J. 1 
6/60 J. 12 

6/12 J. 1 

6/9 

6/60 


Needling 

Needling 

Needling 
Needling 

Needling 

Needling 
Needling 


None 
None 

None 
None 


6/18 J. 1 

6j6 J. 1 

6/6 J". 1 
6/6 J. 1 

6/18 J. 6 

6/18 
6/12 J. 1 


L. did well. 
L. did well. 
L. did badly, No. 

552. 
R. did well. No. 734. 

Vitreous opacities. 

Myopic fundus 

changes. 
L. did well (No. 

951, year 1889). 




1 


Slight iritis , , 
None 

5) 

jj ........ 

K. striata .... 


1/60 

6/36 

6/24 
6/60 

I. 
16/12 J. 2 ! 


6/24 

6/6 J. 1 
6/18 J. 12 

6/60 J. 11 


Needling 
Needling 


Uyalitis 

and 
shrinking 
of globe 


6/18 J. 2 

4/60 


R. operated on else- 
where. Shrunken 
globe. 

R. No. 1784 (year 
1890). 

Capsule. 

3 



198 



ON THE IMMEDIATE AND REMOTE 



[1891 



o 



o3 +r 

CO ^ 



9 
10 
11 

12 
13 

14 
15 



17 

18 

19 

20 

2L 
2i 
23 

24 
25 
26 

27 
28 
29 
30 

31 

32 



Eye. 



472 
522 
621 

673 

689 

1085 
1162 



16 1204 



1275 

1224 

1339 
1356 

1372 
14 4 
1406 

1420 
1494 
1519 

1593 
1612 
1628 
1678 

1693 

1760 



Age. 



33 1784 1 

34 1818 j 1 

35 : 1844 ; 1 



Sex 



52 

70 
36 

74 

71 
65 

72 
65 



63 

65 

65 

68 
4S- 

60 
64 
70 

65 
70 
65 

73 
79 
73 

60 

57 
48 



Condition 
of eye. 



Condition 
of patient. 



Operation. 



Complications 

at time 
of operation. 



F. 
F. 
M. 

M. 

F. 

M. 
M. 



E. 

L. 
R. 
L. 

L. 
E. 

E. 
L. 



Good , 



M L. 



M. 

M. 

M. 
F. 

M. 
M. 
F. 

F. 

M 
M. 

M. 
F. 
F. 

M. 

F. 

M. 



F. 
F. 
M. 



L. 
E. 

L. 

L. 

E. 
E. 
L. 

E. 
R. 
E. 

L. 
E. 
K, 
L. 

E. 

L. 



Corneal ne- 
bula 
Good 



G-ood . 



Usual operation . 



Corneal ne- 
bulae 
Good 



No iridectomy . , 



Usual operation . 



Congenital 

syphilis 
Good ..... 



Myopic- 
Good . . 



Diabetic. 
Good : . 



None . 



None 



Vitreous lost 
None 



Lens matter left 
None 



Hosted by GOOgle 



1891] 



RESULTS OF CATARACT EXTRACTION. 



199 



Secondary 
complications. 



Immediate 
result. 



Remote 
result. 



Secondary 
operations 



Complica- 
tions after 
secondary 
operations. 



Result 
after 2nd 
operation. 



Remarks. 



None 

>? 

Ulceration of 

cornea 

None 

K. striata Pro 

lapse of iris 

Prolapse of iris 

None 

Cystoid scar. 
Iris entangled 
None 

Slight iritis . . 
None 



6/12 

6/18 J. 1 
6/9 



Fingers at 
12" 

6/.» 
6/60 



6/36 

6/60 
6/36 

6/60 

6/24 

6/18 
6/24 
6/18 

6/18 



3/60 
3/60 

6/12 

6/36 
1/60 



6/24 
6/36 
6/6 



6/60 J. 14 

636 

6/24 



1/60 
6/60 J. 19 



6/18 J. 8 

6/18 

6/24 
6/18 J. 4 

6/60 
6/24 



6/9 
6/18 

6/12 



6,60 
6/12 

2/60 



6/36 

6. 18 J. 2 



Needling 

Needling 
Needling 



Needling 
Iridecto- 
my for 
prolapse 

Iridecto- 
my for 

prolapse. 

Capsule 
extraction 
Needling 2 



Needling 
Needling 



Capsule 
extraction 



Needling 



Needling 



Needling 



Atropine 
irritation 



Entangle- 
ment of 
inner lip of 
coloboma 



6/12 

6/12 
6/6 J. 



6/12 J. 10 



6/6 J. 1 

6/6 J. 1 

6/9 



6/18 



6/6 J. 1 



6/12 J. 1 
6/6 



L. extracted else- 
where. Did well. 



R. extraction. No. 
2228 (year 1889) 



Vitreous opacities. 



Yitreou6 opacities. 



Vitreous opacities. 

R. extraction ii 

1887. Did well. 



L. No. 1275. 

Tay's choroiditis. 

Senile dementia. 

Imbecile. 

R. No. 1372. L. cap- 
sule. 

L. extracted in 1887. 
Did well. 

R. extracted in 1875. 
Did well. L. cap- 
sule. 



Hosted by GOOgle 



200 



ON THE IMMEDIATE AND REMOTE 



[1892 



fc 



o, bD 



Eje. 



Age 



Condition 
of eye. 



1 


33 


2 


70 


M. 


L. 


2 
8 


132 
146 


1 

2 


39 
65 


F. 
M. 


R. 
L. 


4 
5 
6 

7 
8 
9 


197 
217 
252 

265 
343 

387 


1 
2 
1 
1 
1 
2 


69 
39 
67 

H2 
33 
62 


M. 
M. 

Jb\ 

F. 
iM. 
F. 


R. 
R. 
L. 
R. 
L. 
R. 


10 


402 


2 


51 


F. 


L. 


11 
12 
13 
14 


424 

502 
582 
603 


1 

2 
1 
1 


71 
69 
73 
69 


M. 
M. 

F. 
F. 


L. 
L. 
L. 
R. 


15 


765 


1 


56 


M. 


L. 


16 


885 


1 


62 


M. 


L. 


17 


1027 


1 


60 


F. 


R. 


18 


1066 


2 


52 


M. 


R. 


19 
20 
21 


1087 
1108 
1113 


1 
1 

2 


40 
66 
61 


F. 
F. 
M. 


L. 
L. 
R. 


22 


1127 


1 


60 


F. 


R. 


23 

24 


1140 
1143 


1 

2 


60 

72 


ML 

F. 


L. 


25 


1269 


1 


54 


F. 


L. 


26 

2? 


1305 
1308 


1 


56 
45 


M. 

F. 


L. 
R. 



Good 

\fyopic . . . . 
Good 

,, ...... 

Syphilitic 
iritis 

G-ood , 

j) 

?) 

Cornea hazy 

Shrunken 
lens 

G-ood 

Projection 

not good 

G-ood 



Condition 
of patient. 



Good , 



Cough 
Good . , 



Operation. 



Complications 

at time 
of operation. 



Conjunctival flap. 
Iridectomy. 
Capsule opened 
with cystotome 

Usual operation . 



Scoop extraction 
Usual operation . 



Scoop extraction 
Usual operation 



No iridectomy . . 
Usual operation . 



None ....... 

)3 

)) 

Vitreous lost 
None 

?j 

>) 

*> 

Vitreous lost 

j» 

None 



Hosted by GOOgle 



1892] 



RESULTS OF CATARACT EXTRACTION. 



201 













Complica- 


Result 






Secondary 


Immediate 


Remote 


Secondary 


tions after 


after 2nd 


Remarks. 




complications. 


result. 


result. 


operations. 


secondary 


operation. 














operations. 






Iritis and P.S 


6/24 






•• 




R. 3 No. 1494 (year 
1891). 




None . , 


4/60 


6/36 


Needling 


None 


6/24 


Central choroiditis. 




K. striata .... 


6/12 










R., No. 1224 (year 
1891). 




None 


6/9 


6/9 J. 1 












,, 


6/60 


6/36 


Needling 


None 


6/6 J. 1 


L., No. 1844. 




» 


6/12 J. 6 
















3/60 










Vitreous opacities. 




Iritis and K.P 


1/60 


1/60 








R., No. 847 (year 
1889). L. Iridocy- 
clitis in 2 months. 




K. striata .... 


6/18 


6/6 J. 1 








R., No. 1784 (year 
1891. 






6/36 


6/2 '4 


Needling 2 


None 


6/9 


Central choroiditis. 




None 


6/9 










R., No. 197. 







6/18 












,, ........ 


2/60 


6/60 


Capsule 


None 


{5/6 J. 1 












extraction 










,, 


Hand- 


1/60 


Needling 


None 


6/12 J. 6 


Capsule. 






movement 














Prolapse of 


3/60 














vitreous 
















Hypopyon P.S 


P. L. 




Gr. caul er v 
to wound. 










None 


3/60 








•• 


L., extraction in 
1885. Did well. 




K. striata .... 


6/36 


6/60 J. 16 


Needling 


None 


6/12 J. 1 


Capsule. 






6/18 


6/12 


Needling 


N one 


6/6 J. 1 






Suppura 


tion 


No P.L. 








L., No. 1339. R,, 
globe shrunken. 




K. striata. 


6/24 


6/24 J. 12 


Needling 


None 


6/18 J. 4 






Atropine irri- 
















tation. Iritis 
















None 


6/9 J. 6 














K. striata and 




.. 








R.extracted,and lost 




iritis 












elsewhere in J 891. 




None 

)> 


6/36 J. 8 

6/12 . 


6;6 J. 1 












K. striata. 


2/60 




Needling. 


Capsule 


Fingers at 






G-laucoma. 






Paracen- 
tesis 2. 
Curette 
evacua- 
tion. Iri- 
dectomy 
down- 
wards. 


adherent 
to scar 


2' 





Hosted by 



Google 



202 



ON THE IMMEDIATE AND REMOTE 



[1892-1893 



J5 



-l_> CO 



Eje. 



Condition 
of eye. 



28 


1353 


1 


75 


F. 


R. 


29 


1355 


1 


77 


M. 


R, 


30 


1378 


1 


63 


M. 


B-. 


31 
32 


1423 
1573 


1 
2 


31 

71 


M. 
M. 


L. 

R, 


33 

34 


1616 
746 


2 
1 


71 
71 


F. 


i) 


35 

36 


1692 
1704 


1 
2 


50 
65 


F. 
F. 


L. 
R. 


37 
38 
39 
40 


J72L 
1722 
1753 

1752 


2 
1 
1 
1 


56 
57 

72 
77 


M. 
M. 
F. 
F. 


R. 
L. 
L. 
L. 


41 


1929 


2 


77 


F. 


L. 


42 


1937 


1 


62 


F. 


R. 


43 


968 


1 


31 


F. 


L. 


44 
45 


871 
1686 


1 
1 


72 
21. 


JVL 

M. 


R. 
L. 



Condition 
of patient. 



Corneal 
nebula 
aood .... 

Corneal 

nebula 
Good .... 
Corneal 

nebulae 

Good .... 
j, .... 

Old iritis and 
coloboma 

Good 

Zonular 
cataract 

Good 



Operation. 



Complications 

at time 
of operation. 



Good 

,, * • . . . 

5) • • • • 

Unsteady . 
Good ..'... 

j, . . . . . 
j? 

3 , i • . . . 

)5 

j, . . . . . 

Good 

Feeble 



Usual operation . 



Scoop extraction 



Usual oj>eration 



No iridectomy 



None 



Vitreous lost 



None 



Iris much 
stretched 



107 


1 


75 


F. 


R. 


291 


1 


90 


M. 


L. 



Conj unctival flap. 
Iridectomy. 
Capsule opened 
with cystotome 

Usual operation . 



None , 



Hosted by GOOgle 



1892-1893] 



RESULTS OF CATARACT EXTRACTION. 



203 













Complica- 


Result 






Secondary 


Immediate 


Remote 


Secondary 


tions after 


after 2nd 


Remarks. 




complications. 


result. 


result. 


operations. 


secondary 
operations. 


operation. 






None 


Fingers 


at 2' 








Capsule. 




»> 


2/60 


6/60 J. 15 


Needling 




6/24 J. 12 


Capsule. Tobacco 
amblyopia. 




» 


6/24 J. 10 


6/12 .1. 2 








Capsule. 






6/60 J. 14 


6/60 


Needling 




6/6 J. 1 


Capsule. 




55 


6/24 


6/24 


Needling 




6/18 J. 6 


L., No. 424. 




Corneal ulcer . 


3.60 


6/60 J. 14 








Some capsule. 




None 


6/60 
6/24 J. 12 


6/18 J. 2 
6/6 J. 1 


1. Needling 
i. Capsule 
extraction 




6/6 J. 1 


R., optic atrophy. 




Prolapse of 


1/60 


1/60 


Needling 




6/12 J. 4 


L. did well. 




vitreous 
















None 


6/18 J. 4 
6'18 J. 4 
6/24 J. 10 


6/12 J. 1 








L., No. 1305. 




K. striata and 
iritis 


6/60 J. 16 




1. Needling 

2. Iridec- 
tomy 


Grlauconvi 


Hand- 
rao Yemeni 






None 


3/60 J. 16 


2/60 








R., extracted in 
1885. Did well. 
Hsemorrl ages at 
and about maculae 
in both eyes. L., 
vitreous opacities 
and capsule. 




K. striata. 


6/60 J. 18 


6/24 J. 12 


Needling 




6/6 J. 1 






Atropine irri- 
















tation. 


















Fingers at 




Iridotomy, 


Vitreous 


6/36 








4'. J. 20 




Needling 


lost 








None 


6/18 


6/24 J. 1 












Post, syn 


1 land- 
movement 


6/6 J. 1 











None 



Iritis. Sympa- 
thetic oph- 
thalmia 



6/18 J. 6 



6/24 J. 12 



Fingers at 
12" 



Followed by sympa- 
thetic ophthalmia 
and serous iritis in 
both. 



Hosted by 



Google 



204 



ON THE IMMEDIATE AND REMOTE 



|"1S93< 



cS __ 



Is -2 








E. 


-P 00 


Eye. 


Age. 


Sex. 


or 


GO (£> 








L. 


°C3 











Condition 
of eye. 



Condition 
of patient. 



Operation. 



Complications 

at time 
of operation. 



3 


374 


1 


57 


F. 


L. 


4 


394 


1 


77 


F. 


E. 


5 


415 


2 


75 


F. 


E. 


6 


433 


1 


70 


F. 


E. 


7 


436 


1 


61 


M. 


L. 


8 


491 


2 


31 


F. 


E. 


9 


578 


1 


68 


M. 


L. 


10 


625 


2 


67 


M. 


E. 


11 


648 


2 


41 


F. 


L. 


12 


663 


2 


71 


F. 


L. 


13 

il- 
ls 

16 


665 
703 
751 
756 


1 
2 
1 
1 


64 
77 
75 
66 


M. 
F. 
F. 
M. 


E. 
L. 
L. 
L. 


17 


772 


1 


80 


M. 


E. 


18 


778 


1 


66 


F. 


E. 


19 


832 


2 


74 


M. 


L. 


20 


912 


1 


58 


F. 


E. 


21 

22 


966 
961 


1 
1 


63 
56 


M. 

F. 


E. 
L. 


23 


984 


2 


60 


M. 


L. 


24 


1044 


1 


78 


M. 


E. 


25 


1146 


1 


Z7 


F. 


L. 


26 


1196 


1 


45 


M. 


L. 



Good Alcoholic . 



Loose lens . . 

Old iritis and 
coloboma 
downwards 

Old iritis, &c. 



Good , 



Loose lens . . 



Good , 



Cb. conjunc- 
tivitis 

Good 

Corneal ne- 
bulas 

Catarrh of 
Lac. sac. 

Good 



Corneal ne 
bulse. Loose 
lens 



Good . 



Deaf , 
Good . 



Feeble , 



Ansemic .... 
Albuminuria 



Usual operation . None 



Scoop extraction 

Extraction down- 
wards 

Scoop extraction 

Usual operal ion . 

Section from 

without inward 
Usual operation . 



Scoop extraction 



Usual operation 



Loss of vitreous 
None 



Fluid vitreous 

lost 
Lens difficult to 

deliver 
None 



Cornea flaccid. 
None 



Soft matter left 
None , 



Lens difficult to 

deliver 
Fluid vitreous 

lost 



Hosted by GOOgle 



1893] 



RESULTS OF CATARACT EXTRACTION. 



205 



Secondary 
complications. 



Immediate 
result. 



Remote 
result. 



Secondary 
operations. 



Complica- 
tions after 
secondary 
operations. 



Result 
after 2nd 
operation. 



Remarks. 



N"one , 



K. striata. 



Iritis and K. 
striata. Glau- 
coma 

Severe iritis . . 

Iritis, &c. 



Suppurative 

iritis 
None 

35 * 

j, ........ 

K. striata 

None 

Is., striata. 
Post, synech. 

K. striata. Cor- 
neal ulcer 

Iritis 

None 

X. striata 

Suppuration . . 

K. striata and 

iritis 
Iritis and P. S. 



6/18 

6/18 J". 8 
6/60 J. 10 

5/60 J". 20 

Fingers at 
12" 

6/9 J. 8 

6/60 J. 18 

6/12 J. 6 

6/18 J". 2 

6/36 J\ 1-4 
6/36 J. 12 
6,12 J". 12 
6/60 J. 19 

3/60 J, 19 

4/60 J". 19 

5/60 J. 20 

6/18 J. 12 

6/24 J. 12 
6/36 J. 15 

6/18 J. 6 



6/24 J. 4 
6/24 J. 12 



6/36 



6/12 J. 4 

Fingers at 
3" 

6/36 



Needling 
Paracen- 
tesis (7) 



Iridectomy 
for glau- 
coma 



Iridoto- 
my (5) 

Excision 



Needling 



Needling 



6/18 J. 6 
6/12 J". 6 



4/60 J. 18 
6/12 J. 6 

Hand- 
movement 



6/60 J. 19 I 1. Capsule 
J extraction 
| 2. Needling 
6/36 J. 19 J Capsule ex" 
t ruction 
Paracen- 
tesis 



6/12 J. 8 Needling 
6/36 J. 1 



6/18 J. 6 

6/6 J. 2 
1/60 J. 20 



1. Gr. cau- 
tery 

2. Excision 



Needling 



Grlaucoma 



Loss of 
vitreous 



Vitreous 
lost 



1/60 J". 19 



Fingers at 
2' r 



Fingers at 
12" 



6/J 2 J. 6 
6/18 J. 6 



L., No. 1752 (year 
1892). 



Pupil muck drawn 

up. 
R. blind from optic 

atrophy, &c. 

L., No. 968 (year 
1892). 

L., No. 1162 (year 

1891). 
R., No. 1087 (year 

1892). 
R, No. 397 (year 

1893). 

R., No. 394. 



Capsule. Optic atro- 
phy and central 
choroiditis. 
6/60 J. 19 Vitreous opacities. 



6/6 J. 1 



6/12 J, 6 



1/60 J. 20 



»., No. 871 (year 
1892), 



Fundus changes. 

R., No. 1763 (year 
1S89). 

Primary suppura- 
tion. 



Vitreous opacities. 



Hosted by 



Google 



206 



ON THE IMMEDIATE AND REMOTE 



[1893-18821 



u 










Is ^ 








K„ 




Eye. 


Age. 


Sex. 


or 


1* 








L. 



Condition 
of eye. 



Condition 
of patient. 



Operation. 



Complications 

at time 
of operation. 



28 
29 
30 
31 

32 
33 



35 

36 
37 

38 



1470 

1494 
1556 
1557 
1601 

1628 
1648 



34 1677 



1752 

1901 

1961 

164 



25 

68 
69 
71 
58 

61 

75 



58 



28 

67 
64 
32 



F. 



M. 

F. 
M. 
M. 



Zonular 

cataract 
Good .... 

Proj ection 

bad 
Good .... 
)> • ♦ • • 

55 • • • • 

55 • • • • 

55 • • • • 

Good .... 



Good 

55 . . . ■ 

55 * ' * 

Alcoholic 
Good . . . 

55 * * • 

Good 



Unsteady . . 



Usual operation . 



None , 



Sticky lens 



None . 



1 


82 


1 


68 


M. 


R. 


2 


103 


1 


53 


F. 


R. 


3 


104 


1 


67 


M. 


L. 


4 


116 


2 


62 


M. 


R. 


5 


152 


2 


66 


M. 


R. 


6 


260 


2 


53 


F. 


L. 


7 


280 


1 


82 


M. 


R. 


8 


331 


2 


59 


F. 


L. 


9 


355 


2 


68 


M. 


L. 


10 


469 


1 


33 


F. 


I- 



Section upwards. 
Iridectomy. 
Capsulotomy 
done with, cys- 
totome 



Usual operation. 
Soft matter 
scooped out 

Usual operation . 



None . 



Soft matter left 

Some vitreous 
lost 

Lens required 
much manipu- 
lating to re- 
move it. Iris 
bruised, &c. 

None 



Hosted by 



Google 



1893-1889] 


RESULTS OF 


CATARACT 


EXTRACTION. 


207 




Secondary 
complications. 


Immediate 
result. 


Remote 
result. 


Secondary 
ope ratio qs. 


Complica- 
tions after 
secondary 
operations. 


Result 
after 2nd 
operation. 


J 

Remarks. 


| 


None 

Slight iritis and 

entropion 

Ncne 

K. striata. 

Inner angle 

of coloboma 

entangled 
None 


6/18 J. 1 

6/36 J. 16 
6/60 J. 15 
6/24 J. 12 
6/18 J. 12 

6/24 J. 10 
1/60 

6/36 J. 19 

6/36 

6/36 J. 15 
6/24 J. 12 
6/12 J. 1 


6/9 J. 1 
6/60 J. 15 
1/60 J. 19 
6/12 J. 1 

6/9 J. 1 
6/36 J. 4 

Fingers at 
12" 

6/18 J. 4 
6/18 J. 4 
6/9 J. 1 


Needling 
Needling 

Needling 


K. striata 


6/9 J. 1 
6/6 J. 1 

6/24 J. 12 
6/6 J. 1 


L., No. 1686 (year 
1892). 

Lost from pympa- 
thetic after ex- 
traction of R. R. 
remained good. 

Yitreous opacities. 
R. healthy. 


r 


None 


L. extracted, No. 






1423 (year 1892). 



Iritis and P.S. 



Iritis and K.P. 
Slight iritis . . 

Iritii and P.S. 



None 

Iritis and P.S. 

Suppuration . . 



None „ < , 6/36 J. 10 



J. 20 



6/24 J. 12 
J. 20 

6/24 

6/2 i J. 6 



6/36 J. 12 

6/60 J. 18 
6/60 

Hand 
movement 



6/12 J. 2 



6/24 J. 12 
6/24 J. 12 
6/18 J. 12 



6/12 J. 2 



Needling 
Needling 



None 



6/6 J. 1 
6/12 J. 1 



L. did fairly well. 

R. capsule. 
L. did w ell. 



R. did well. 
No. 103. 

R. did well. 

R. did well. No. 82. 



Hosted by 



Google 



208 










01s 1 


THE IMMEDIATE AND 


REMOTE 


[1885 


© 
o 
o 
6 


.—1 © 

CO <L> 


%e. 


Age. 


Sex. 


R. 

or 
L. 


Condition 
of eye. 


Condition 
of patient. 


Operation. 


Complications 

at time 
of operation. 




11 


617 

691 

S31 
866 

915 
1004 

1007 

1061 
1064 
1116 
1170 
1363 

1421 

1747 
1779 
1824 

1919 

1922 

2022 

2034 

2075 
2179 

2219 

2257 


2 

1 
1 
2 

1 
1 

1 

2 
1 
1 
2 
1 

1 

1 
1 
1 

1 

1 

1 

1 

1 
1 

2 
1 


82 

48 
82 
69 

56 
66 

59 

59 

68 
48 
65 

62 

48 
61 
76 

73 

65 
65 

69 

65 

70 

75 
64 


M. 

M. 
F. 
M. 

F. 
M. 

M. 

M. 
M. 
F. 
F. 
M. 

F. 

F. 

F. 
M. 

F. 

F. 
M. 

M." 

F. 

M. 

F. 
F. 


L. 

R. 
L. 
R. 

R. 
L. 

R. 

L. 
L. 
L. 
R. 
L 

L. 

L. 
R. 
L. 

L. 

R. 
L. 

R, 

R. 
L. 

R. 
L. 


Good 

55 

Not good . . . 
Good 

t + .!!!!! .' 

Good 

Brown nu- 
cleus 

Projection 
bad on 
nasal side 

Good 

55 •♦.... 
55 

Cornea nebu- 

lous 
Projection 

fair 

Good 

Trace of old 

iritis 

Good 

55 


Good 

Bad health 
Good 

55 

Cough 

Good ...... 

Fair 

Good 

55 

55 ...... 

55 

55 

Fair 

Good 

Cough 

Paralysis 
agitans 


Usual operation . 

55 5) 
55 55 
55 55 

55 55 
55 55 

55 55 
55 55 
55 55 

>> 55 

55 55 
55 55 
55 55 

55 J5 

55 55 
55 55 

55 55 
55 55 


None 




12 






13 


" 




14 


" 




15 

16 

17 

18 
39 


Soft matter left 

Much manipu- 
lation in de- 
livering lens 

Iris dragged 
upon 

Iris torn 

None 


1 


20 




1 


21 




1 


22 


" 


1 


23 
24 


Lens matter 
scraped out 

None 


i 


25 






26 


" 




27 






28 






29 


" 




30 






31 






32 

33 


Soft matter 
rather difficult 
to remove 

None 




34 













Hosted by GOOgle 



1889] 



RESULTS OF CATARACT EXTRACTION. 



209 



Secondary 
complications. 



Immediate 
result. 



Remote 
result. 



Secondary 
operations. 



Complica- 
tions after 
secondary 
operations. 



Result 
after 2nd 
operation. 



Remarks. 



None 

Severe iritis. . 
Slight iritis . . 

?5 J) * • 

Iritis 

Slight iritis.. 
None 

Slight iritis . . 

Spasmodic en- 
tropion 

Iritis 

None 

Slight iritis . . 
None 



1/60 

6/60 J. 18 
6/60 J. 16 
3/60 J. 19 
6/36 J. 12 



6/36 
3/60 



J. 18 



6/60 J. 8 
6/60 J. 16 
J. 16 



1/60 



6/24 .T. 6 
6/36 J. 16 


6/9 J. 1 


6/36 


6/6 J. 1 


6/60 J. 8 
6/18 J. 6 


6,6 J. 1 
6/9 J. 1 


J. 20 

6/12 J. 2 


6/18 J. 2 
6/6 J. 1 



6/6 J. 1 
6/60 
6/6 J. 1. 

6/9 J. 1. 



6/36 J. 8 
6,9 

6/24 J. 18 



6/12 J. 2 
6/18 J. 1 
6/12 J. 1 



6/24 J. 12 



Needling 



None 



6/24 J. 6 



R. did well. 

No. 280. Some 
lens matter re- 
mained. 



L. extraction, fol- 
lowed by iritis. 



R. did well. 
L. did well. 



R. lost from trau- 
matic ulcer and 
excised. 



L. did well. 



Hosted by 



Google 



210 



ON THE IMMEDIATE AND REMOTE 



[18ft 



( 



Fh 










— 1 <V 








K. 




Eye. 


A.ge. 


Sex. 


or 
T, 


°P3 










W 











Condition 
of eye. 



Condition 
of patient. 



Operate 



Complications 

at time 
of operation. 



9 
10 



11 
12 



13 
14 



15 



14 



125 



379 

404 



444 
466 

665 
666 

706 

724 



779 

868 



89S 
942 



947 



16 1021 

17 1067 

18 1090 



1 


61 


F. 


1 


51 


F. 


2 


64 


F. 


1 


47 


F. 


1 


63 


M. 


2 


70 


M. 


1 


59 


F. 


2 


74 


F. 


2 


65 


M. 


2 


69 


M. 


1 


69 


F. 


1 


76 


F. 


1 


62 


F. 


2 


67 


M. 


2 


50 


F. 


1 


63 


F. 


1 


56 


vr. 


1 


56 


f. ; 



Myopic 



High myopia . 
Old iritis 
and P.S. 
T. - 1. 
Projection 
bad 

Good 

Old iritis and 
P.S. Pro- 
jection bad 
T. - 

Vitreous 
opacities 

Good 



R. Cortex fluid 
L. • Projection 
bad, amber 
coloured 
nucleus 
Good 



Myopic 



Good 



Good 



Section upwards. 
With iridec- 
tomy. Capsule 
opened with 
cystotome 

Usual operation . 



Usual operation, 
but incision w r as 
enlarged 

Usual operation . 



None . 



Soft matter diffi- 
cult to remove j 

Soft matter 
scraped out 
with curette 

Iris fell before 1 
the knife 



None 

Soft matter left 

None 

)> 

None 



Hosted by GOOgle 



890] 



RESULTS OF CATARACT EXTRACTION. 



211 



Secondary 
complications. 



Immediate 
result. 



Remote 
result. 



Secondary 
operations. 



Complica- 
tions after 
secondary 
operations, 



Result 
after 2nd 
operation. 



Remarks. 



None 



Iritis. . 



,, purulent . 
None . < 

j) ♦ * 

Spasmotic en- 
tropion 

Iritis. 

None 

Iritis and glau- 
coma 

None 

I ritis 

Iritis P. S 

VOL. XIT. 



6/36 



P. L. 



6/9 J. 1 
No P. L. 



6/12 J. 4 
6/12 

6/60 
6/60 

6/6 



3/60 
Hand- 
movement 



5/60 
Hand- 
movement 



6/24 J. 12 



2/60 J. 19 



6/18 



6/18 

6/12 

6/6 J. 1 



5/60 J. 2 



Needling 



.None 



6/60 



6/9 J. 1 

Counts 
fingers 



6/24 



6/9 J. 1 



Needling(2; 



Needling 



Hand- 
movement 



6/24 



Vitreous opacil ies 
and choroidal 

atrophy. 



L. did well. 



V. again failed ; 

cause not stated. 
L. extraction did 

well. No. 2179 

(year 1889). 

L. did well. No. 
1919 (year 1889). 

L. did well. No. 

2022 (year 1889). 
R. did well. Central 

choroiditis and 

optic atrophy five 

years later. 
Choroiditis. 



Some old choroiditis. 

L. did badly after 
extraction else- 
where. R. vitreous 
opacities and cho- 
roiditis. 

R. did fairly well. 
L. iridocyclitis a 
year after extrac- 
tion. V. = 6/24. 



Hosted by 



Google 



212 



ON THE IMMEDIATE AND REMOTE 



[1890-189 



^ 



Eve. 



Condition 
of eye. 



Condition 
of patient. 



Operation. 



Complications 

at time 
of operation. 



19 

20 
21 

22 



24 



25 

26 

27 
28 
29 

30 
31 

32 



1104 

1121 
1176 

1218 



23 1233 



1261 



1447 
1476 

1476 
1492 
1493 



33 1645 

34 1902 

35 1902 



2 50 



Good. 



1521 1 
1494 1 



1522 



M. 

M. 



R. 



Hyperraature 

cataract 
Catarrhal 

conjunctly 

itis 
Good 



R. Projection 
bad 



Good 

Morgagnian 

cataract 
Good 



57 


1 


28 


M. 


L. 


Coloboma 
upwards 




2 




n 


R. 


Post. syn. . . 



G-ood . . . 

,, . . . 
,, . . . 

Diabetic 
Good . . 



Usual operation . 



No iridectomy. . . 



Usual operation 



None 



Albuminuria 



After preliminary 
iridectomy. 

With iridectomy. 
Conjunctival 
flap. Capsule 
opened with 
cystotome 



Iris much 

stretched 

Lens removed 
with hook after 
much difficulty 
and the loss of 
much vitreous. 
It hitched be- 
neath iris 

None 

a ......... 

n • * 

>j 

>? * 

a ' ' 

ii .....•«•• 

Much soft mat- 
ter left 
None 

)> • * 

ii 

ii • * 

None 



Hosted by GOOgle 



890-1891] 



RESULTS OF CATARACT EXTRACTION. 



213 



Secondary 
complicatioms. 



Immediate 
result. 



Remote 
result. 



Secondary 
operations. 



Complica- | 
tions after I 
secondary I 
operations, 



Result 

after 2nd 
operation. 



Remarks. 



Iritis and P.S. 

Severe iritis. . . 
None 



1 6/24 



Slight iritis . . 6/36 



Prolapse of iris 
Iritis. 



None . o . . 

Very slow lieai- 6/1 8 1 
ing of wound 

None 6/9 * 

Severe iritis 

None 6/36 ' 



Iritis 




4/60 



6/9 J. 1 

6/60 



6/24 J. 10 



Needling 
Needling 



Irideeto 



Needling 



None 



6j6 J. 1 



6/24 



None 



6/9 J. 1 



None 



6j6 J. 1 



R. had severe iritis, 
but did well. No. 
691 (year 1889). 

Patch of choroiditis. 



L. old blind eye. 
L. detached retina, 

&c, after blow. R. 

also has detached 

retina. Myopia 

both. 



L. lost after extrac- 
tion elsewhere. 

Wants needling. 

L. did fairly well. 

No. 467 (year 

1889). 
L. did well. 



None 



6/24 
3/60 J. 19 



1/60 
6/12 J. 4 



P 2 



Hosted by G00gle 



214 



ON THE IMMEDIATE AND REMOTE 



[1891-1801 













.1=; *=o 


Eye. 


Age. 


Sex. 


R 
or 
L. 


a 











10 

11 

12 
13 
14 
15 
16 
17 



18 
19 



20 
21 

22 
23 

.24 



185 
180 
302 
305 
473 

482 

517 
544 

654 

722 
823 
104] 
1054 
1078 
1213 



1253 

1284 



1315 
1345 

1349 
1402 
1367 



25 1758 



Condition 
of eye. 



M. 
F. 
M. 
F. 
F. 

M. 

M. 
F. 

M. 

M. 
F. 
F. 
M. 
F. 
M. 



F. 
M. 

F. 
F. 
F. 

M. 



Condition 
of patient. 



Operation. 



Complications 
ai-' time of 
Operation. 



Good. 



L. Projection 
not good 
L. (jood 



aood , 



Diabetes. 



Good , 



With iridectomy 
No iridectomy . . 



With iridectomy 

Scoop extraction 
with iridectomy 
With iris^-^my 




/Difficult to d 
liver 
Vitreous lost. 



After prelimirj aT T 

iridectomy \ 
With iridectomy 
No iridectomy! • • 
With iridectomy 
No iridectomy) ' ' 
With iridectomy 
No iridectonr 



None 

Iris fell before 

knife 
None 



I Irid ecto my eJ* : te r 
extraction J 

"No iridectomy ' ' 
V-itli ind/ ctom y 
Wo HA^.fol^y . • 



1 


212 


2 


66 


F. 


R. 


2 


228 


1 


65 


M. 


B* 


3 


229 


1 


70 


M. 


R. 


4 


421 


1 


59 


F. 


R. 



Good , 



Ch. rheuma- 
tism 



Conjunctival flap. 

No iridectomy. 

Capsule opened 

with cystotome 
Usual operation. 

No iridectomy 
With iridectomy. 

Iris transfixed 

No iridectomy . . 




Soft matter left 
None ■ 



Hosted by 



Google 



891-1892] 



RESULTS OF CATARACT EXTRACTION. 



215 



Secondary 
complications. 



Immediate 
result. 



Remote 
result. 



Secondary 
operations. 



Complica- 
tions after 
secondary 
operations. 



Result 
after 2nd 
operation. 



Remarks. 



None 



Iritis. 



Iritis in two 

months 
None 



Iritis 



K. striata. 
None .... 
Iritis .... 
None .... 



Prolapse of 
iris 

None 

Prolapse of iris 



6/24 
2/60 
6/36 

6/60 J. 15 
6/12 J. 1 

6/9 J. 1 

6/12 
Hand- 
movement 
3/60 J. 16 

6/12 

6/12 

6/9*' 

6/36 

1/60 



6/6 J. 1 

6/24 



6/6 J 1 

6/12 J. 1 
6/18 J. 1 
6/24 

6/36 J. 12 



6/6 J. 1 
6/36 

6/60 J. 8 
6/36 J. 10 



Iv. striata 
Iritis .... 



6/60 

6/12 

6/9 

6/36 

6/60 

6/12 



6/24 J. 12 



6/36 
6/9 



Needling 
Needling 

Iridectomy 
for pro- 
lapse 

Prolapse 
returned 



Needling 



Iris re- 
mained 

caught in 
wound 



6/6 J*. 1 
6/6 J. 1 

6/60 J. 16 



6/9 J. 1 



6/9 J. 2 



1st eye did well six 
years ago. 

Lens matter present. 

R., No. 1494 (year 
1890). Capsule. 



L., No. 473. 

L. extracted fire 
years ago else- 
where. Did well 

L., No. 823. 



Wants needling. 



Iritis followed 
blow. 



Iritis and P.S. 



Slight iritis . . 

Iridocyclitis 
and K. punc- 
tata 

Prolapse of iris 



3/60 



6/24 J. 15 

Hand- 
movement 

6/18 



6/24 



Iridectomy! 
for pro- I 
Inpse i 



L. extracted six 
years ago. Dense 
membrane. 



Hosted by GOOgle 



216 










ON 


THE IMMEDIATE AND 


REMOTE 


[1892-1893 


sc 

c3 
o 
if-, 
o 

6 




Eye. 


Age. 


Sex. 


R. 

or 
L, 


Condition 
of eye. 


Condition 
of patient. 


Operation. 


Complications 

at time 
of operation. 




5 
6 
7 


435 
596 

667 

691 

752 

1015 

1021 

1345 
1520 

1534 

1933 


1 

2 
1 
2 
1 
1 
2 

1 
1 

1 

1 


57 
54 
62 
76 
57 
82 
70 

73 

70 

39 
51 


F. 
F. 
F. 
F. 

F. 
F. 
M. 

M. 
F. 

M. 

M. 


L. 
R. 
R. 
L. 
R. 
L. 
L. 

R. 
L. 

L. 

R. 


Good ...... 

j, ...... 

j, ...... 

Old iritis and 

coloboma 
Epipliora . . 

G-ood 

,, ...... 

jj ...... 

Myopia .... 

aood 


Ch. bron- 
chitis 
)) 

aood 

33 

33 

Feeble .... 
aood 

Unsteady . . 
aood 

33 

33 


After preliminary 

iridectomy 
No iridectomy . . 

Iridectomy after 

extraction 
After previous 

iridectomy 
With iridectomy 

No iridectomy . . 
With iridectomy 

3) 33 

After preliminary 

iridectomy 
With iridectomy 


None 

33 •••••... 




8 

9 

10 

11 

12 
13 

14 

15 


Vitreous lost . . 

Vitreous pre- 
sented 

Difficult to 
deliver 

Loose lens .... 

Soft matter left. 
C, flaccid 

Fluid vitreous 

lost 
Iris buttonholed 


1 



1 


9 


2 


49 


M. 


R. 


2 


149 


2 




M. 


L. 


3 

4 
5 


238 
304 
349 


1 

1 
1 


64 
66 


M. 

F. 
F. 


R. 
L. 
R. 


6 

7 


481 

574 


1 
1 


64 
54 


M. 
M. 


R. 
L. 


8 


597 


2 


58 


F. 


R. 


9 


683 


1 


54 


F. 


R. 


10 


850 


2 


61 


F. 


R. 


11 


873 


1 


53 


F. 


L. 



aood ...... 

3 5 

33 

Oldhypopyor 

ulcer 
aood 



aood .... 

Unsteady, 
aood 



Conjunctival flap. 
Iridectomy. 
Capsule opened 
with cystotome. 

With iridectomy 



Iris buttonholed 



None 

Vitreous pre- 
sented 
None 

None 

33 

Soft matter left 



Hosted by GOOgk 



] 892-1893] 



RESULTS OF CATARACT EXTRACTION. 



217 



Secondary 
complications. 



Immediate 
result. 



Remote 
result. 



Secondary 
operations. 



Complica- 
tions after 
secondary 
operations. 



Result 
after 2nd 
operation. 



Remarks. 



Iritis 

None 

Iris adherent 

to scar. Iritis 

None 

Iritis 

None 

Prolapse of iris 

None 

Iritis and hypo- 
pyon 
None 



6/24 

2/60 

6/18 J. 4 

1/60 

Hand- 
movement 
6/60 J. 15 

6/36 J. 4 



6/60 
Hand- 
movement 
1/60 

6/24 J. 6 



6/24 J. 10 
6/12 J. 12 



P. L. 

5/60 
6/18 J. 4 



Needling 
Needling 

Needling 



Iridectomy 
for pro 
lapse 



Needling 



6/6 J. 1 
6/6 J. 1 

6/18 



6/24 J. 1 



L., No. 1041 (year 
1891). 



R., No. 1750 (year 
1891). 



Hypopyon in six 

weeks. 
Fundus changes. 

Vitreous opacities. 





None 

1 


6/12 J. 6 
6/9 J". 4 


6/6 J. 1 








L. did well six years 
ago. 

R., No. 1933 (year 
1892). 


p 


None 


6/24 J. 10 


6/9 J. 1 












Post syn 


6/9 J. 4 














Cyclitis, &c. . . . 


Hand- 
movement 


•• 






•• 


L. lost from hypo 
pyon ulcer. 




K. striata .... 


6/12 J. 6 


6/18 J". 1 












K. striata and 


1/60 J. 20 


Fingers at 


1. Iridec- 




1/60 






glaucoma 




IS" 


tomy (2). 

2. Needling 

3. Paracen- 
tesis. 










Slight iritis . . . 


1/60 J. 19 


2/60 J. 19 


Needling 




6/18 J. 6 


L., No. 435 (\ear 
1892). 




None 


6/12 J. 1 








•• 


L., No. 12S4 (vear 
1891). 


; Iritis and P. S. 


Hand- 














movement 1 












None 


6/24 J. 8 


6/18 J. 10 


Needling 




6/6 J". 1 





Hosted by GOOgle 



218 



ON THE IMMEDIATE AND REMOTE 



[1893} 



12 
13 



14 

15 
16 

17 



IN 
10 
20 



21 
22 



23 






Eye, 



Sex. 



Condition 
of eye. 



1142 


1 


53 


M. 


R. 


1346 


1 


58 


M. 


R. 


1359 


1 


77 


M. 


R. 


1384 


1 


63 


M. 


L. 


1481 


1 


65 


M. 


R. 


1619 


1 


59 


F. 


R. 


16-15 


1 


79 


M. 


R. 


1671 


2 


53 


M. 


X. 


17u7 


2 


66 


F. 


L. 


1743 


1 


62 


M. 


L. 


1839 


1 


59 


M. 


L. 


1865 


1 


45 


F. 


L. 



Good.,.. 
)j .... 

,, .... 

Projection 

not good 

Good .... 

Myopic. . . 



Projection 
not good 

Hypermature, 
Very tough 
capsule 



Hypermature 



Condition 
of patient. 



Operation. 



Good . . . . 

Alcoholic, 
diabetes 
G-ood 



Alcoholic . 



With iridectomy 

After preliminary 

iridectomy 



With iridectomy 



Capsule forceps 
tried, but failed. 
Cystotome used. 
Hook extrac- 
tion. Vitreous 
lost. 

With iridectomy 



Complications 

at time 
of operation. 



None 

>) 

Removed with 
difficulty 

C. flaccid 

Soft matter left 



None 



Hosted by GOOgle 



1893] 



RESULTS OF CATARACT EXTRACTION. 



219 



i 










Complica- 


Result 






Secondary 


Immediate 


Remote 


Secondary 


tions after 


after 2nd 


Remarks. 




complications. 


result. 


result. 


operations. 


secondary 
operations. 


operation. 






None 


6/36 J. 8 


6/6 J. 1 












Suppu 


ration 




1. Gr. cau- 
tery. 

2. Removal 
of lymph. 

3. Excision 






Primary suppura- 
tion. 




K, striata 


6/60 J. 15 


6/18 J. 1 


•• 


•• 


•• 


Central choroiditis 
in both. 




Iritis and P. S. 


6/36 J. 8 


6/6 J. 1 








R., No. 481. 




None 


Hand- 
movement 


1/60 


Needling 




6/24 ' 






Postsyn. Iritis 


Fingers at 
6" 


3/60 J. 14 


Membrane 
divided 


•• 


6/24 J. 12 




1 i 






with scis- 
















sors 












1/60 


6/18 J. 8 












Iritis 


6/60 J. 15 


6/24 J. 6 


Needling 




6/6 J. 1 


R.,No. 1142, 




None 


6/36 J. 16 










Choroidal atrophy 


■ 












and Titreous opa- 














cities. R., No. 14 














(year 1890). 




Iritis and K. 


6/60 J. 18 


6/6 J. 1 












striata 
















None 


1/60 

6/24 


1/60 
6/9 J. 1 


NeedliDg(2) 




6/12 J. 6 





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220 



CONTRACTUEE AND OTHEE CONDITIONS FOLLOWING 
PARALYSIS OF OCULAE MUSCLES. 

By W. T. Holmes Spicer. 

Recorded cases of high degrees of contracture of the 
muscles of the eye following paralysis of their opponents 
have not been very numerous in the literature of English 
ophthalmology ; the following cases are of interest from 
a consideration of their causation, and also as presenting 
a series of varying degrees of contracture from their 
highest to their lowest forms. The existence of con- 
tracture may be unsuspected, and the attempt to divide 
an organically shortened muscle may present difficulties, 
owing to the contracted space in which the operation has 
to be performed, the consequent danger of wounding the 
sclerotic, and the great toughness of the fibrous bands 
into which the muscle has been converted. Free expo- 
sure of the tendon is necessary, and successive bands 
must be divided far back until the globe can be brought 
into a more correct position; it is sometimes impossible to 
use a squint-hook owing to the difficulty of introducing it 
beneath the tendon. The prognosis must always be a 
guarded one where the contracture is of long standing, 
as the muscle is, to a greater or less extent, functionless, 
owing to the change in its structure, and if the operation 
succeed in rectifying the faulty position, it will not 
restore a proper range of movement to the eye. 

The question of what part paralysis of a muscle and 
subsequent slight contracture of its opponent play in the 
development of concomitant squint arises out of the con- 
sideration of contracture itself; among a large number of 
patients, cases often appear in which a fully-developed 
convergent squint, confined to one eye, has appeared 
suddenly during strain, produced by a fit, or attack of 
vomiting or coughing ; the resulting limitation of move- 



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CONTRACTURE FOLLOWING PARALYSIS. 221 

merit is considerable, and the phenomena are not easily 
explained by their association with hypermetropia, or by 
the presence of a congenital muscular insufficiency. These 
cases occur mostly in infants during a time when the 
tunics of the eye are soft and yielding; the development 
of astigmatism as a consequence of a defect of traction in 
a muscle acting on such a plastic eyeball is possibly a 
considerable element in the production of the amblyopia 
of squinting eyes. 

Paralysis of 2nd, Uh, hill, 6th, 1th, and 8th Cranial Nerves ; 
Partial Paralysis of 3rd ; Secondary Contracture of Internal 
Pectus. 

Minnie M., aged 5 (V. H. Ill, 447), came to the Victoria 
Hospital on April 24, 1893. There was a history of slight 
ophthalmia in both eyes just after birth, not enough to attract 
the doctor's attention. Her mother is sure that she has had no 
other illness ; her face was noticed to he drawn to one side 
shortly after birth ; she had no sign of a fit or other cerebral 
affection at any time. 

The birth was natural ; instruments were not used. There 
is no history of syphilis either personal or in the family. 

There is complete facial paralysis of the right side, the 
orbicularis does not act, the cornea is exposed by the falling 
away of the lower lid. The eyeball is dry, and the secretion of 
tears seems to be diminished. The cornea is densely opaque 
and covered with a horn ol dried mucus, which projects 
between the lids and gives the child a somewhat repellent 
appearance ; she has been sent away from school as she 
frightens the other children ; the whole eyeball is completely 
insensitive ; it was possible to scrub its surface hard to remove 
the mucus without giving any sensation. The right side of the 
face is insensitive ; all the divisions of the 5th nerve are 
affected ; all the teeth of both upper and lower jaws on the 
right side are carious and broken off to the level of the gums ; 
the teeth of the other side are quite sound. 

There is incomplete ptosis on the right side ; the lid is partly 
held up by the levator palpebras, The right eye is alnaust 



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222 CONTRACTURE AND OTHER CONDITIONS 

immovable ; it is kept in a position of convergence, and only a 
limited amount of horizontal movement is possible with it ; there 
is no vertical movement. 

There is no perception of light ; smell and hearing are 
doubtful, but she does not seem to hear on the affected side. 

The movements and vision of the left eye are normal. 

The mother asked that the eye might be removed, as it was 
so unsightly ; under anaesthetic it was enucleated. 

The eyeball could not be drawn out straight on account of 
the rigid and shortened internal rectus ; there was no matting 
together of the orbital tissues; the globe was not adherent; 
there was no sign of past orbital cellulitis. The socket healed 
normally. 

An examination of the optic nerve showed it to be atrophic ; 
a fragment of the internal rectus muscle was examined ; it was 
very fibrous, but a certain amount of muscular tissue was 
present ; there was no fatty change. 

In this case the 2nd, 3rd, 4th, 5th, 6th, 7th, and probably 
the 8th cranial nerves were involved ; parts of the 3rd nerve 
had either escaped or had recovered their function, there 
was only partial ptosis, the internal rectus acted feebly 
and was contracted. The escape of certain branches of 
the 3rd nerve points to the orbit as a possible seat of the 
lesion, but apart from there having never been any sign 
of protrusion or of retraction of the orbital contents 
there was also involvement of the other divisions of the 
5th nerve and of the 7th nerve. It is probable that the 
lesion causing the paralysis was in the middle fossa of 
the skull, the optic nerve anterior to the chiasma being 
also involved. The purely unilateral character of the 
paralysis would exclude a nuclear affection. 

A slowly-growing tumour would be a possible expla- 
nation, except that there had been no progression of the 
disease since birth ; the most probable cause was a 
chronic meningitis of the base, possibly of syphilitic 
nature, occurring during foetal life or during the first few 
weeks after birth. 



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FOLLOWING PARALYSIS OF OCULAR MUSCLES. 223 

Contracture of Internal Rectus of High Degree. 

Minnie L., aged 5, came to Mr. Nettleship's clinic, Moor- 
fields, on October 26, 1889. 

Convergent squint was noticed first when she was 6 weeks 
old ; it had always been present since ; it appeared to change 
from one eye to the other at times. There was no history of 
injury. 

October 30. Under atropine V. R. = 6/24. No improve- 
ment. V. L. = <6/60e +1 D.S./ + 2 D. cyl. Ax = 6/24. 

High degree of convergent strabismus, which appears to 
alternate, and is of a higher degree in the left eye. 

As the patient came from a distance and the squint was of 
such a high degree, operation was advised at once ; the left 
internal rectus was divided under anaesthetic, and the operation 
called for no remark. 

November 27. The convergence does not seem diminished. 
Under ether, tenotomy of the right internal rectus was per- 
formed. After introducing the speculum and grasping the 
conjunctiva by fixation forceps, it was found that the eye could 
not be drawn out at all ; it was firmly fixed by the internal 
rectus. An incision was made over the lower border of the 
taudon, but it was not possible to introduce the hook beneath 
the muscle, which formed a tense rigid band ; the incision was 
prolonged upwards over the insertion of the tendon, the con- 
junctiva was dissected back, and the tendon fully exposed ; it 
was then divided without much difficulty. After a free divi- 
sion, the eyeball could be drawn out fully ; there was no further 
limitation to its movement. The conjunctiva was sutured. 
Glasses were ordered : R. +T5 D. sph. ; L. +2 D. cyl. Ax. | . 

December 4. The eyes are straight and the movements 
fairly good. 

March 12, 1890. The eyes are straight. 

In this case an early paralysis of the R. external rectus 
left the internal rectus unopposed ; the eyeball was 
gradually drawn over to the inner canthns, the muscle 
itself underwent shortening and kept the eyeball fixed in 
its new position ; the external rectus afterwards recovered- 
power, but was unable to overcome the shortening of its 



Hosted by G00gle 



224 CONTRACTURE AND OTHER CONDITIONS 

opponent. The secondary deviation of the opposite eye, 
brought about when the formerly paralysed muscle tried 
to overcome the shortening of its contractured opponent, 
gave an appearance of alternation to the squint, and even 
made the squint appear greater in the L. eye. 

High Degree of Convergence with Contracture of the Internal 

Rectus. 

Agnes P., aged 8, came to Mr. Grunn's clinic, at Moorfields, 
on Jnly 26, 1892. She is said to have always sqninted ; the 
nurse present at birth asserts that the L.E. was turned in from 
the very first. 

The child has always had good health ; never had fits nor 
skin eruptions ; there were no other children, and no mis- 
carriages. 

Convergent strabismus of the L. of a high degree, upwards 
of 45°; the movement to the L. is very defective, the eye 
cannot be made to turn out beyond the middle line. 

Refraction, after atropine, R. Ht., 4*5 D. L. +5 D. She 
was ordered -f 3 D, to wear constantly. 

November 25, 1893. Still very high degree of convergence. 
Tenotomy L. int. rect. Y. Graafe's operation under chloroform 
by Mr. Grunn. The eye was firmly held to the inner canthus ; 
it could not be drawn out enough to open the conjunctiva well. 
After opening Tenon's capsule, everything was divided as far 
back as possible^ but still the eye could not be drawn out ; the 
adhesions of the muscle to the deeper parts of the sclerotic 
were extremely dense and difficult to divide, but after careful 
and repeated attempts all the adhesions were divided and the 
eyeball could be moved out. 

Contracture following Paralysis of External Rectus. 

Edith B., aged 9 (Y. H. Ill, 495), came to the Victoria 
Hospital on June 19, 1893. 

She began to squint at 9 months of age, during an illness, 
said to be measles ; she was an 8 months' child. There was a 
history of miscarriages in the family, but there had been no 
signs of syphilis in the child ; she had not had snuffles nor skin 



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FOLLOWING PARALYSIS OF OCULAR MUSCLES. 225 

eruptions, and was not unhealthy looking ; she had, however, 
had thrush very badly. 

There was a very high degree of convergence with the L. ; 
on attempting to look to the L. there was a certain amount of 
movement outwards, but not beyond the middle line ; it could 
not be maintained in mid-position, but was unsteady. 

V. R., 6/18. Refraction of R. +1 D. V. L., 6/60. Refrac- 
tion of L. not easy to determine on account of the convergent 

+ 1 

position of the eye, but probably X • Under chloroform 

. +2 
tenotomy of the L. internal rectus was performed. Under the 
anesthetic the eye remained strongly convergent, and could 
only be brought out with some difficulty, but the contracture of 
the internal rectus could be overcome by the hook introduced 
beneath it ; it was then divided. 

She had +1D. sph. given her. 

A year later there was still a considerable degree of con- 
vergence. 

In Cases 1, 2, and 3 the peculiarity in the eyes was 
noticed as soon as the eyes were seen, that is, within the 
first six weeks of birth, and in none of them was there 
anything to explain the cause of the condition ; the 
children had not apparently been suffering in any way, 
and there was nothing in the family history to account 
for the peculiarity. The contracture was less marked in 
the first case, for the reason that there had probably been 
a complete paralysis of all the muscles of the eye, but that 
some of them had recovered a certain portion of their 
activity, and shortening had taken place in them to a 
degree proportional only to the amount of recovery. 

In the second case the squint was noticed at 6 weeks 
of age, and in the third case the nurse said that the squint 
was present at birth, so that in these two cases a very 
high degree of contracture took place as the result of a 
congenital paralysis ; this is stated by Mauthner to be very 
uncommon. 

The fourth case was an instance of a much smaller 



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226 CONTRACTURE AND OTHER CONDITIONS 

amount of contracture, resulting from a paralysis of the 
external rectus in infancy, in which the shortening could 
be overcome by firm tension on the shortened muscle : in 
all the three latter cases the paralysed muscle had regained 
its activity, so that it was difficult to distinguish them 
from cases of concomitant squint depending on a high 
degree of insufficiency of one external rectus. 

If a muscle be paralysed there is nothing to resist the 
action of its opponents, the eye at first remains in a 
neutral position, and simply fails to make any movement 
towards the paralysed side ; but if the paralysis persist, 
the eye is gradually drawn more and more to the side of 
the active muscle and retained there. Contracture, that 
is an actual diminution in length of the mnscle, rapidly 
follows, so that the eye is prevented from returning to its 
former position by the mechanical shortening of the con- 
tractured muscle. 

This is analogous to what takes place in infantile 
paralysis, where the onset of paralysis of a group of 
muscles in a limb is followed, after a time, by an actual 
shortening in the muscles of the opposing group, so that, 
if neglected, the limb becomes permanently fixed in a 
new vicious position. Further, owing to want of use, the 
muscles of the active group undergo a certain amount of 
atrophy. 

This contracture, when once reached, is permanent, 
but its degree varies with the duration of the primary 
paralysis. When the paralysed muscle completely and 
quickly regains its power, it is unable, if contracture has 
come on at all, to overcome the shortening of its opposing 
muscle, and re-establish parallelism of the visual axes : its 
range of action is limited by the amount of shortening 
which has ensued : as a consequence, the eyes take up a 
new position of convergence towards each other, in which 
their range of action may be very nearly full, and a con- 
dition which it is impossible to distinguish from concomi- 
tant strabismus is established. 



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FOLLOWING PARALYSIS OF OCULAR MUSCLES. 227 

Where the recovery from the paralysis is only partial, 
or has been postponed, there may be an intermediate 
condition, in which it is not easy to determine whether 
the squint is concomitant or is due to a previous paralysis. 
In extreme cases, that is, where the paralysis has remained 
permanent, it is stated that the contractured muscle is 
converted entirely into a fibrous band, while the eye 
remains immovably fixed in the angle to which it has 
been drawn by the shortened muscle (Mauthner, Vor- 
trage II, 638). 

It is also stated by Wecker and Landolt (III, p. 851) 
that contracture will develope in the healthy eye when it 
is excluded from fixation. 

As to the significance of paralysis of single ocular 
muscles, it is noteworthy that they occur nearly always in 
the external rectus; there is nothing in the anatomical 
condition of the muscle itself which it does not share with 
the other eye muscles, and the reason for the comparative 
frequency with which it is attacked is to be found in the 
long course of the 6th nerve, between its origin at the 
front of the anterior pyramid and its termination in the 
muscle. Paralysis of the external rectus occurs in all 
states of refraction, in myopia and emmetropia occasionally, 
but most commonly in hypermetropia ; this is owing to 
the greater relative frequency of hypermetropia among 
children. In a certain number of cases recovery is prompt 
and complete ; in others it is only partial, and the muscle 
is permanently weak, or contracture of its opponent ensues. 

The most common history of the cases is that the 
squint was noticed to come on suddenly during a temporary 
illness. Convulsions are a frequent alleged cause, or 
bronchitis or whooping cough, or teething. It has been 
noticed before that convergent squint of sudden onset is 
very commonly associated with an attack of whooping- 
cough. As a rule, the cases are not seen at the earliest 
period because the mother almost invariably says she has 
been told that the child would grow out of it, This 
VOL. XIV. Q 



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228 CONTRACTURE AND OTHER CONDITIONS j 

implies a widespread belief among parents, if not among f 

doctors, that the occurrence of squint is a very common \ 

condition, and is one that is mostly recovered from spon- 
taneously. Possibly this is so, and the cases that persist 
form a small proportion only of the total number that 
occur. 

Sudden paralysis of this kind would probably be the 
result of a hemorrhage into the sheath of the nerve. 
Gowers (Dis. Nerv. Syst, II, p. 191), says :—" Paralysis 
of an ocular muscle may be apparently the result of 

haemorrhage into its sheath, compressing the fibres 

This mechanism is not uncommon, and may depend on a 
special arrangement of the blood vessels. The cases come 
within the general law that an organic lesion of actually 
sudden onset is always vascular, due to rupture or 
occlusion of a vessel. An onset during strain renders 
rupture scarcely questionable." 

In the intense straining produced in the child during 
whooping cough, or a bad attack of bronchitis, or a fit, 
there are all the conditions necessary for the onset of a 
haemorrhage. The paralysis must be regarded as a 
traumatic one, due to an extravasation of blood into the 
sheath of the nerve, brought about in the same way as 
haemorrhages from the nose, or beneath the conjunctiva, 
or from the meninges, which are not uncommon during 
whooping cough- 
But it may be that these are not cases of paralysis at 
all ; they may be concomitant squint brought about by 
the relationship of the convergence to the accommodation. 
But, if so, how can we explain their sudden onset and 
permanence, their complete development at once, the 
definite limitation of movement which they show, their 
occurrence in one eye only, and their persistence after 
atropinisation, and the neutralisation of their refractive 
error. Their occurrence, too, in emmetropic eyes, or in 
eyes with small amounts of hypermetropia, cannot be 
explained on the accommodation-convergence hypothesis 



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FOLLOWING PARALYSIS OF OCULAR MUSCLES. 229 

unless we assume that after an exhausting disease, like 
whooping cough, the accommodation shares in the general 
weakness, and the excessive effort to exercise it results in 
the production of an excess of convergence. But, on the 
one hand, failure of vision is not present in these cases as 
it is in diphtheritic cycloplegia, and, on the other, the 
actual weakness of the accommodation, widen does occur 
after diphtheria, does not bring about convergent squint, 
except rarely in a late stage of the affection, when the 
loss of accommodation is being recovered from. In order 
to explain these cases it is inevitable to assume either a 
previous paralysis or an insufficiency of one external 
rectus. It is difficult to determine which of these two 
causes is the correct one, although it might be thought 
that a congenital insufficiency would most probably be 
bilateral, and would show itself from the beginning, as 
soon as the eyes came to be used at all. 

Coming now to the effect on the conditions of refraction 
and form of squinting eyes, there are some peculiarities 
which are almost constant. 

When a squint is purely concomitant, and alternating, 
and no paralysis or inequality of muscles is present on the 
two sides, there is, as a rule, only hypermetropia of 
greater or less amount present ; astigmatism, if present, is 
equal in the two eyes, and, as a rule, there is no serious 
defect of vision. But in a permanent squint limited to one 
eye it is practically always the case that the squinting 
eye is more astigmatic than its fellow; it is not always 
more hypermetropic ; it frequently happens that the 
amount of the H. in the meridian of least refraction is 
less than that in the other properly directed eye. Next, 
in almost all the cases, the astigmatism is according to 
rule; that is to say, the vertical meridian is the one of 
greatest refraction; in other words, there is more EL in the 
horizontal than in the vertical meridian. 

The association of these three factors — a convergent 
squint due to a defect of one external rectus, a flattening 

Q 2 



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230 CONTRACTURE AND OTHER CONDITIONS * 

or diminution in the curvature of the horizontal meridian 
of the cornea, and the occurrence of amblyopia in the 
deviated eye — is so common that it is difficult not to 
believe that there is some relationship of cause and effect 
between them. 

A paralysis or insufficiency of one of the horizontal 
muscles like the external rectus will lead to a displace- 
ment of the eye by the opposing muscle, but it does not 
mean that there is greater tension on the eye by that 
muscle than in the normal state ; it exerts the same power 
of traction, that of a muscle of normal tonicity, but its 
tonic action is unopposed. Consequently the sum of the 
powers of traction in the horizontal meridian is less than 
normal. As a consequence of the diminished traction 
exerted in the horizontal meridian of the eye, there will 
ensue a flattening of this same meridian ; that is, a produc- 
tion of H. in the horizontal meridian. The amount of this 
flattening will be great in proportion to the plasticity of 
the eye ; that is, in proportion to the earliness of the occur- 
rence of the defect. 

There is an interesting observation bearing on this 
made by Priestley Smith, in vol. iv of the Ophthalmic 
Review, p. 354. A lady suddenly had paralysis of the 
external and internal recti of one eye of rheumatic origin, 
the other muscles of the eye being unaffected. In testing 
her refraction, she was found to have 1 D. of My. As. in the 
vertical meridian, by the shadow test ; a cylinder of that 
strength with its axis horizontal gave her almost normal 
vision. After treatment the movements of the eve were 
completely re-established, and all trace of the astigmatism 
disappeared. 

Further, in a fair number of eyes affected with squint of 
this kind, if the refraction of the eye be worked out in 
other part of the fundus, it will be found that the altera- 
tion in curvature is not confined to the cornea alone ; the 
equatorial and posterior regions of the eye often undergo 
very considerable alteration in curvature. 



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FOLLOWING PARALYSIS OF OCULAR MUSCLES. 231 

This change is sometimes very great ; it is more marked 
in eyes in which the squint comes on where there has been 
widespread choroido-retinitis such as occurs in syphilitic 
hildren, in which it is easy to think that the globe has 
ssed through a period when it was more yielding than 
al, and during this period has yielded to the unequal 
ure exerted on it by the recti muscles. 
a certain number of cases of convergent squint the 
'ng eye deviates up as well as in; if the squinting 
wed to fix and the other eye be covered, its 
viation is sometimes internal purely, and 
sometim do n and in. This form of deviation is pro- 
bably die t0 a peculiarity in insertion of the internal 
rectus; ffnc&s ( v * ^raefe's Archiv., xxx, 4 ; 1) found that 
considerable "^ cr«ljr us exis ted in the relative distances of 
the interfial and e xterna ^ rect ^ from tae cornea, in many 
eyes the J differenc? s being as much as 2'5 mm. In only 
half the leases were t ^ e nisertions symmetrical as regards 
the horiz ontal meri(^ an > 0De or otner nmscle being raised 
or deprei ssed ; in abP ut ^alf t ^ ie cases tne li ne of insertion 
was not ]3erpendicul aT ^° ^ ie horizontal meridian. The 
insertion^ f the supeF or au( ^ H1 ferior re cti exhibited more 
asymmeiliy^ and there\ were consiCL erable variations in the 
extent ok the line of ink rtion ' 

In soijne of the case\ w ^ ere ^is upward deviation of 
the squinting eye exists' t ' ie direction of the principal 
meridians f refraction &^ ^ e cornea * s oblique ; the 
obliquity of these meridi- JS * s P ossu:) ly due to an obliquity 
in the direction f ;-- --^rtion of the muscles into the globe. 
In working) out the refraction of the eye in its different 
parts, accurate measurement is not easy, on account of the 
difficulty of' being sure that the same region of the eye is 
being exar nrne d when making comparisons with the nor- 
mally directed emmetropic or hypermetropic eye. For 
this reason^ estimation by the erect image is unreliable ; 
but with i'he shadow test, carried out at a fixed distance, 
the visua 1 ax i s °f the observed eye being always directed 



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2^2 



CONTRACTURE AND OTHER CONDITIONS 



at the same angle of deviation, an approximately accurate 
result can be obtained. 

In the following cases, in which the refraction has beer 
worked out in more than one part of the fundus, th§ 
results are given ; generally, all parts of the eye share 
the change in form, but it is most marked in the re£ 
outside the yellow spot. The observations have not, 
numerous enough to form any conclusion as to the 
stancy of the direction and degree of change prodry 
the altered muscular conditions, but they sho^ 
change does exist, and that it is often of 
extent. These cases are only selected on&^is oprrt many 
others observed, in which the same cha^*^ e ^a&noted, but 
its degree not recorded. / 

The sequence of events in the ^^ 3r ° r fc, fj^Ji of the 
change in the eye is, first, paralysis, < >r what ar ja unts to 
the same thing, the sudden onset of j ngu ffi c i e r/cy of one 
external rectus ; next, a change in tlj e curva tlre of the 
cornea, a flattening of its horizontal mer i c ji an Ihown by 
the presence of astigmatism accord]^ to mle . at the 
same time a change in the curvature, Q £ ^j ie gc i e ro tic, due 
to altered traction on its outer siui£ a This results in 

changes more or less seriously affl ecting tlie position of 
the fovea, and its accurate adjust m[ eilt to tte ray Jg f light 
focussed on it. Amblyopia, of / eftter Qr le * s degree, 
would be a consequence of this % ange in the C1 ^ :v ature or 
adaptation of the fovea ; a chaj^ ge £ thlg part r) f the eye, 
too small to be measured in diop? veg ^ mig h t Je t be produc- 
tive of considerable amblyopia. AiL^i j 8 , so produced 
is made permanent and irrecoverable by y^ant of use of 
the channels of communication, and of the visual centres 
or by a failure of their complete development if the 
squint has begun before the habit of proper c en t ra l fixa- 
tion has been acquired in the squinting eye. / 



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FOLLOWING PARALYSIS OF OCULAR MUSCLES. 233 

Convergent Squint of Left Eye after Fits in Infancy. Change in 
Shape of the Globe. 

Eliz. M. came to Mr. Gunn's clinic, at Moorfields, in Feb- 
ruary, 1894. 

She was aged 29 years. She had fits in early infancy, 
before she was a year old; she did not squint when she was 
born, but did so suddenly after the fits. The L. always turned 
in very much, but the R. was straight ; eight years ago she had 
tenotomy of both internal recti in the country ; both eyes were 
operated on many times. 

There is now some divergence of the L. ; both internal recti 
fail to act, either in lateral or converging movements. 

V. E,., 6/6 Hm. 25 D ; V. L., not improved. R., shadow 
test, no As. ; L., shadow test. 



Nasal side. 


At. 


Y.S. 


Tempi, side. 


Like T. S. 




+ 2 


+i 







+ 3 


— 



Ophth. no astigmatic crescent. 

Old Paralysis of L. Ext. Rectus. Conv, Strabismus. Change in 
Shape of Globe. 

Geo. D., 12, came to Mr. Gunn's clinic, at Moorfields, in Jan- 
uary, 1895. 

No history was obtainable. 

Definite weakness of L. ext. rectus ; it can with difficulty be 
made to go out just beyond the middle line ; its fixation becomes 
nystagmoid in attempting to look to L. Under atropine the 
movements are the same. 

Under atrop. R. 6/18. c+lD = 6/6. L. 6/36 not im- 
proved. 

Y.S. TemiDl side. 

Refr. ofL. +1 -|3 

I 2*5 



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234 CONTRACTURE AND OTHER CONDITIONS 

Refr. of R. 

4-1-5. 

Same in other parts of fundus. 

Convergent Squint with Change in Shape of the Globe. 

Charlotte D., aged 10 (Yict. Hospl., 2433.) 

She began to squint at 3 years of age, after a series of fits ; 
she had glasses at 3-| years of age ; has worn them constantly. 

January, 1895. There is now moderate convergence of the 
R. ; external rotation is less complete than that of the L. ; the 
R. is permanently on a lower level than the L. 

Y. R., fingers at 1 ft. not improved. Y. L., 6/9. 

Shadow test under atropine. 



Temporal side. 


At Y. S. 


Nasal side. 








R. +3-5 


+ 3-5 




L. 


+ 5 


— 


— +3 


— 


— + 6 


likeY. S. 




— 


—+5-5. 



Convergent Squint. Change in Shape of Globe. 

Elsie M., aged 12, (Yict. Hospl., 2440.) 

Began to squint suddenly in childhood; had glasses 12 
months ago. 

There is moderate convergent squint with R. now, but no 
marked defect of movement, and no difference in the two sides. 

Y. R., 6/18 ; Y. L., 6/12. 

Under atropine. Shadow. 



B. tempi, side. 

-2-5 

-1-0 



At Y. S. 
-2-5 



— + 3-5 



L. 



Emm. 
+ 3. 



Convergent Squint. 

George McGr., aged 9, came to Mr. Nettleship's clinic, at 
Moorfields, in February, 1895. 

He had squinted since whooping cough at 3 years of age ; 
he had the cough very badly at the time; he had glasses two 
years ago. 



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FOLLOWING PARALYSIS OF OCULAR MUSCLES. 235 

There was still moderate squint. 

V. R., 6136, not improved ; V. L., 6/12 c + 4D = 6/6. 

Under atropine. Shadow. 



Tempi, side. Y. S. Nasal. 

+ 3 X /+-4 +3v/+6 +3 X// + 6 



i 



Convergent Squint. 

Ed. W., 10, wan brought to Mr. Gunn's clinic, at Moorfields, 
in March, 1891. 

He had brain fever at 14 months, but it is not known when 
he first squinted, as his parents are dead. He has squinted 
ever since he was 3 years old. 

There is a high degree of convergent squint ; it is not easy 
to determine the refraction, as he keeps his eyes closed. Was 
given -f 4*5 D. sph. to wear. \ 

November, 1891. — Tenotomy R. Int. "Rect. j 

March, 1895. — Four years later. Outward movement good ; 
no squint. 

Tempi, side. Y. S. 

Refr. R. +7 +8 L. + 6 

- + 7 — I — + 10 + 8. 

"Early Strabismus producing Deformity of the Eye. 

Antoinette S., aged 6. 

She squinted at 9 months of age. 

Mod. convergent squint with R. E. ; outward movement can 
be obtained. 

Y. R., 6/60 c -f- 4 D = 6/9 ; V. L., 6/60, not improved. The 
refraction varies considerably in various parts of the fundus, 
bat she is too unsteady to determine it at all accurately. 

Conv. Strabismus. Alteration in Shape of Globe. 

Annie H., aged 11. (Metrop. Hospl.) 

January, 1895. — Fell out of a barrow, at set. 4, on her head ; / 

the squint came on after; it was not noticed before. ■ 



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r 



2 36 CONTRACTURE FOLLOWING PARALYSIS. 

R., high degree of convergence about 45°, with upward 
deviation also.* Movements are full. 

Y. R., 6/60; Y. L., 6/18, no improvement, 

Under Atropine. Shadow. 



1 
To tempi, side of R. 
-1 


R. \y + 2 


L. 


+ 3-5 


— 1— + 5. 


/\ + 6 




— 


— + 4 • 



Ophth., nil. No crescents. 

Internal and Upward Deviation of one Eye ; Astigmatism witli 
Oblique Meridians. 

Wm. H., 7, came to Mr. Gunn's clinic, at Moorfields, Eeb- 
ruary, 1895. 

R. convergent since birth; has had glasses elsewhere two 
years ago. 

Has high degree of convergent squint in R. E., slight 
upward deviation also. 

R., fingers at 1 m. ; L., 6/12 + 2 D = 6/6. 

R. \/ + 2 L. + 3 

/\ + 4 ' — I 1-3*5. 

Inward and Upward Squint, with Obliquity of Axis of the 
A stigmatism, 

Edith S., aged 9. Convergent squint for many years. 
(Y. TL, iii, 431.) 

R. deviates 15° in and 10° up. On covering the L. and 
making the R. fix, the secondary deviation of the L. is in and 
down. 

Under atrop. R., fingers at 2 m. ; L., 6/18 c + lD = 6/6. 

Shadow. \ / — 0*5 






I am indebted to Messrs. ISTettleship and Gunn for permis- 
sion to use their cases. 

* The puneta laehrymalia being equal in height, the cornea of the U. E. 
is entirely above the pnncturo, when the L. E. fixes a point straight in 
front ; when the B. E. fixes, the L. E. is covered to the edge of the pupil 
by the punctum. 



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237 



SEROUS CYCLITIS. 

By ET. C. Ridley, late Acting Curator, B.L.O.R. 

This disease is known also by the names serous irido- 
cyclitis or serous uveitis, according as the anterior part or 
the whole of the uveal tract may have been involved, and 
formerly was frequently termed descemetitis or keratitis 
punctata, from the presence of dotted opacities seen when 
light is transmitted through the cornea. 

As its anatomical characters have hitherto been very 
scantily worked out, I venture to think that a record of a 
series of cases which I have recently had an opportunity 
of observing, and in several instances microscopically 
examining, may be of interest. 

The following is a list of causes of this disease given 
by authors, examples of many of which will be found in 
the accompanying series : — 

1. Syphilis. — a. Congenital. 

b. Secondary acquired. 

c. Tertiary. Gumma of the ciliary body. 

2. Sympathetic trouble after injury to the other eye. 

3. Traumatism. 

4. Gonorrhoea. 

5. Uterine disease. 

6. Rheumatism. 

7. Gout. 

8. Diabetes. 

9. Intra-ocular growths involving the ciliary region, 
including tubercle. 

10. Spreading of inflammation from neighbouring 
parts. 

11. Following acute specific fevers. 

Besides those due to the above causes, many cases 
occur in which no cause can be found to which they can 
be definitely attributed, and these are called idiopathic. 



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238 SEROUS OYOLITIS. 

In spite of wide difference of etiology, roost of the 
cases presented many points in. common in their clinical 
history and course, and also in histology where oppor- 
tunity offered. 

In all the well-marked cases there was great injection 
of the episcleral vessels, especially at the sclero-corneal 
junction, accompanied by more or less pain, ciliary hyper- 
esthesia, and loss of vision. On examination, the media 
were hazy and the vitreous was seen to contain floating 
opacities. The iris escaped in most of the cases, but, 
when involved, exhibited the ordinary signs of iritis, viz., 
alteration of colour, dulness of lustre, sluggish reaction, 
and contracted pupil. In some instances a total or partial 
paralysis of the ciliary muscle was present, and in others 
slight photophobia and lachrymation. 

In the table below, to avoid repetition, I have only 
put those symptoms that were especially marked or at all 
exceptional. 

On examining with focal illumination a number of 
greyish dots were noticeable on the cornea, arranged 
roughly in the form of a triangle, with the apex at the 
centre and base downwards, but frequently distributed 
over the whole of the surface, and when large looking 
like round specks of grease. On direct illumination with 
a powerful convex lens, the opacities could be seen to be 
on the posterior surface. 

All the cases which continued under observation for 
some time were subject to occasional exacerbations of 
pain, ciliary tenderness, and redness, with a tendency to 
increased intra-ocular tension, the latter sometimes rising 
to T. + l or +2. 

Those with high intra-ocular tension could be divided 
into two groups, in one of which there was an anterior 
chamber shallower than usual, with dilated pupil as in 
primary glaucoma, and the second in which the anterior 
chamber was increased in depth ; with a pupil of about the 
normal size. The anatomical reason lor this difference 



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SEROUS CTCLITIS. 



239 



was apparent on examination of specimens of each gronp 
which were removed, and will be referred to later on. _ 

The decrease in acuity of vision spoken of, was attri- 
butable in the earlier stages to the haziness of the media, 
but subsequently to the increased tension and to accom- 
panying choroido-retinal changes. 

There are many papers on record referring to examples 
of this disease occurring from various causes. Brailey 
mentions an instance} where an attack of cyclitis seemed 
to replace an acute Vattack of gout in a gouty patient. 
Trousseau, Saulay, Ccihn, and De Weckert record cases 
apparently dependentW uterine disease or gonorrhoea, 
and attribute it either \o the micro-organisms or then- 



products getting access 



menstrual period in the first case, or after some special 



irritation as of catheterisat 



ion in the second. 



* Trans. Opt 
t Reference 



to the blood, either at the 



h. Soc, toI. x, 98. 
3 in lit. at end. 



/ 



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240 



SELIOUS 0T0L1TIS. 



No. 



Patient. Age. 



Female 



Female 26 Several months, 



Female 



Male 



20 A few 



20 



20 



Duration 
of attack 

before 
treatment. 



Present attack 
2 months. 



Eye 
affected, 



L. 



Both 



V«i< 



\V; = 2/60. 
i\ot improved 
b 7 glass. 

kv; = 6/6 j. i. 

N <> Hm. 



E. V. normal. 
L. diminished. 



R. normal. 

L. = 6/36 J. 15. 



Symptoms, &c. 



"Very marked universal 
" keratitis punctata." 

Deep A. C. 

Much ciliary injection. 

Pupil active. Media 
hazy. Much pain. 

T + 1. Ciliary tender- 
ness. Very anseniic. 



The appearance at first 
was very like that of a 
phlyctenule;, the swell- 
ing and injection being 
more marked at a loca- 
lised spot on the outer 
side. 

Later symptoms as in 
Case 1. 

Marked K. P. Deep 
A. C. Ciliary injec- 
tion, &c 



Much K. P. Deep A. C. 
Pupil active. Ciliary 
injection > &c.> T + 1. 



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SEROUS OYOLITIS. 



241 




Two months before, she 
had knocked the eye acci- 
dentally, but had not 
noticed anything wrong 
until a day or two before 
attending. She had never 
had any serious illness, 
and had no menstrual 
trouble. No family his- 
tory of tubercle. Her 
father gave a very indefi- 
nite history of syphilis 
when a young man. 



The eye first gave trouble 
soon after the birth of 
her first child^ about a 
year after marriage, at 
which time she had a bad 
sore throat. 



? Congenital syphilis 5 eyes 
had been weak since 
childhood. Had " ery- 
sipelas and rheumatic 
fever" 2 years before. 
Inflammation began in 
both almost simultane- 
ously about 3 years be- 
fore admission. Recovery 
apparently took place, as 
also from a second attack 
later. They have recently 
become inflamed again, 

Two months before ad- 
mission some spots were 
first noticed in front of 
L. eye. No change had 
taken place during that 
time. No history of 
syphilis, &o. About 11 
years before patient re- 
ceived a blow over L 
eyebrow, ami saw spots 
for some time afterwards. 



Treatment and course, 



Result. 



The anaemia was treated 
with arsenic and iron, 
and atropine and dark 
glasses were ordered. 
The anaemia improved, 
but the eye symptoms 
got worse till V. = P,L. 
only. 

Mercury and iodide of 
potassium in small 
doses were then tried 
for a time, and the 
eye seemed to improve, 
but her general health 
suffered, so they were 
discontinued. Shortly 
after she went away 
into the country. 

Mercury j iodide of po- 
tassium, Atropine, 
dark glasses. There 
were several relapses. 



Weak atropine solution. 

Dark glasses. 
Repeated paracentesis 

of A.C, 



Same as Case 3, 



A year after the 
beginning of the 
attack the con- 
dition is : R. eye 
has remained well 
throughout. L.V. 
= 2/60. Tn. No 
ciliary injection 
nor tenderness. 
A.C. normal. 

Cornea perfectly 
clear. Pupil ac- 
tive, secondary 
reaction > pri- 
mary. Yitreous 
contains fibrous 
tissue. There is 
slight paresis of 
L. ext. rectus. 

Disease came to an 
end, but vision of 
left eye was per- 
manently dam- 
aged. 



Some improvement. 



Slight improve- 
ment. 



Remarks. 



Although there 

were no other 
signs of congenital 
syphilis j I think 
the partial im- 
provement under 
iodide of potas- 
sium, and the ap- 
pearance of paresis 
of the ext. rectus 
rather point to this 
as the cause. 

It was remarkab-e 
that the R. eye 
escaped ; it may be 
that the slight in- 
jury to the L. was 
the determining 
factor in the case. 



Still under treat- 
ment 



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242 



SEROUS CYOLITIS. 



Bo. 


Patient. 


5 


Female 


6 


Male 


7 


Female 


8 


Male 



Age. 



19 



26 



24 



10 



11 



Male 



Male 



Male 



Duration 
of attack 

before 
treatment. 



Three week3. 



Thirty-three 
days 



Six weeks. 



8 A few hours. 



24 



30 



A few hours. 



Eye 

affected. 



R. 



L. 



L. 



R. 



L. 



Yision. 



P.L, only in 
affected eye. 



R. = P.L. 



ISTo P.L. in L. 



L. = P.L. 



R. »s= fingers at 
30 cm. 



Symptoms, &c. 



Symptoms very acute. 
Only very fine and slight 

K. P. 
A. 0. fairly deep in 

centre. 
T + 1. 

Yery little reflex. 
Acute pain, redness, and 

tenderness. Slight 

K. P. Shallow A. 0. 
Small wound at inner 

sclero- corneal junction 

with prolapse of iris. 

Numerous posterior 

synechia?. 
Cornea clear. A, C. 

shallow above, deep 

below. 
Whole eye filled with a 

wash leather coloured 

mass, with numerous 

blood vessels on it. 

Tn. 



Cornea very hazy. 

Marked K. P. 

A. C. rather deep, and 
contains a large quan- 
tity of inflammatory 
material. T + . 

Iris prolapsing through 
corneal wound. 



A. C. shallow. 



Localised swelling of 
outer ciliary region 
Slight K. P. Iritis. 
A. C. normal. T + , 
tender. 



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SEROUS CTCLITIS. 



243 




No history of rheumatism, 
tubercle, or syphilis. On- 
set was sudden, patient 
thinking she had got a 
lash in it. She then found 
it was blind. ? Injury 
7 years before. 

Three weeks previous to ad- 
mission patient was struck 
in H. eye. 



Patient received a blow in 
the eye with a skijjpmg 
rope. 



Patient was struck in the 
eye with a fork. 



Patient was struck 
eye with a peg top. 



Wounded in ciliary regj' 
with a piece of steel, i 



History of syphilis 
years before. 



Treatment and course. 




A new growth was 
diagnosed and the eye 
removed. 



Eye removed. 



New growth ^as diag- 
nosed ■ '*' the eye 
remo^ . 



Eye removed. 



Fifteen weeks later the 
eye was removed, as it 
' ad afterwards be- 
co. le inflamed and 
painful. 

The eye apparently got 
well, but after a week 
or two became painful, 
and the vision failed. 
Eye removed. 

Diagnosed gumma of 
ciliary body. Treated 
with iodide of potas- 
sium and atropine. 



Recovery. 



Remarks. 



Specimen, 
and 8. 



Figs. 7 



Mi croscopically 
there were appear- 
ances of the kind 
mentioned in 

Group I. below. 



The vitreous cham- 
ber was found to 
contain new 

formed fibrous 
tissue, whose con- 
traction had caused 
the deepening of 
the A.C. in the 
lower part, and 
total detachment 
of retina. 

Condition of the 
kind mentioned in 
Group II. below. 



Specimen, Fig. 9. 



Inflammatory ma- 
terial in the meshes 
of the suspensory 
ligament. 



VOL. XIV. 



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244 



SEROUS OYCLITIS. 



No. 



12 



13 



14 



Patient. 



16 



Female 



Male 



Male 



Male 



Age. 



Duration 

of attack 

before 

treatment. 



50 Present attack 
a few davs. 



26 



Eye 
affected. 



Male 



35 



15 



4 
ninths 



Probably only 
a day or two. 



Probably only 
a day or two. 



E. 



E. 



Both 



Both 



Vision. 



< 6/60. 
L. = 6/6. 



Nil 



l'} = 6/6 J. 1, 
with correction. 



17 I Male 14 



18 



Male 



19 



Several years. 



E. 



f-X = 6/6 J. l,, 



E. 
L 
with correction. 



Nil 



Nil 



Several years. 



E. 



Nil 



Symptoms, &c. 



Fine diffuse K. P. 

Much ciliary injection. 
A. C. deep. 

Iritis and many poste- 
rior synechia?. 

Central part of cornea 
ulcerated. Pan n us 

above. Lower part 
clear. 

A. C. very deep. T + . 

Fine general K. P. in 
both. No other symp- 
tom nor sign whatever 



Fine general IC. P. in 
both. No other symp- 
tom nor sign whatever. 



Cornea very hazy. No 
A. C. T +2. Pupil 
occluded. 



Cornea clear, but 
wounded, A. C. con- 
tained blood. 



Cornea opaque. Ciliary 
staphyloma. * Lens 
opaque and calcareons 
lying in A. C. 



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SEROUS CYCL1TIS. 



245 




Patient had had many 
attacks of what was said 
to be rheumatic iritis. N o 
other history of import- 
ance. 

The eye was said to havt 
been affected since in- 
fancy. Chronic keratitis 
from granular ophthalmia. 



Patient attended at the 
hospital to have his re- 
fraction corrected. He 
admitted that he was then 
suffering from gonorrhoea. 

Like Case 14, he attended 
at the hospital to have his 
refraction corrected. He 
was very anasinic. There 
was no history of con- 
genital syphilis, gonor- 
rhoea, nor tubercle. 



After pupil had been 
dilated as much as 
possible, weak atro- 
pine and dark glasses 
were ordered. 

Eye removed. 



Patient went elsewhere 
for treatment and has 
not been seen since. 



Atropine, gr. | to 33, 
prescribed twice a day. 
Dark glasses, iron ad- 
ministered. 



Considerable 
provement. 



Mother first noticed some- New growth was diag 
thing wrong with the eye 
19 days before. No his- 
tory of importance could 
be obtained. 



Wound 12 days previously. 
The eye had been acci- 
dentally found to be blind 
4 years previously. There 
was no history of injury 
preceding the blindness, 
nor of any general dsease 
to account tor it. 

Eye accidentally found to 
be blind 5 years before. 
Had recently become 
painful. JN T o history of 
injury, &c, to be elicited. 



nosed, and the eye re- 
moved. 



Still under treat- 
ment. 



Eye removed. 



Eye removed. 



Pigmented cells and 
leucocytes in sj aces 
of Eontana. 



On examination, 
changes due to cy- 
clitis were found. 
The anterior part 
of the uveal traet 
was chiefly affict- 

Exam ination showed 
blindness was due 
to old cyclitis. 
Specimen, Eigs 1 
and 2. 



Atrophy of whole of 
u v e a 1 t r a c t. 
Several strong fibr- 
ous bands were 
found traversing 
the vitreous cham- 
ber in various di- 
rections. Total 
detachment of re- 
tina. 

R 2 



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246 



SEROUS CYOL1TIS. 



No. 



Patient. 



19 



20 



Male 



Female 



Age. 



Duration 
of attack 

before 
treatment. 



Eye 
affected. 



Yision. 



21 



22 



Female 



Both. L. = nil. 
L. worst 



Both 



25 



Female 



6 

mirths 



23 



24 



Female 



Male 



Both 



L. 



;6/60 



Nil 



42 



Three days. 



Six weeks. 



L. 



E. 



E = P. L. only. 
L. normal. 



Symptoms. &c. 



Slight K. P., A. C. shal- 
low. The yitreoub 
contained a flocculent 



Marked K. P. 
A. C. T + . 



Dee]) 



Marked diffuse X. P. 
Deep A. 0. T + . 



Cornea hazy in centre, 
bulges forwards con- 
siderably. T + . Pain- 
ful. 



A. C. deep Yellow re- 
flex. Painful. Slight 
K. P. 

A. C. deep. Large spots 
of K. P. Much injec- 
tion. T — 1. Lens 
opaque. 



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SEROUS CYCLITIS. 



247 





History. 


Treatment and course. 


Eesult. 


Remarks. 




First one eye was affected, 


L. eye removed. 




Showed the appear- 




then the other. No his- 






ances men fcioned in 




tory bearing on the affec- 






Group I. below. 




tion could be obtained. 










Patient suffered from endo- 


After the uterus was 








metritis, and it was no- 


curetted, the eye 








ticed that the two affec- 


symptoms improved, 








tions varied coincidentally 


and there was marked 








in intensity. 


diminution of intra- 
ocular tension on more 
than one occasion. 








Patient says that her eyes 


Atropine, gr. \ to 3], 


Patient is slowly 


On examination by 




are most painful at about 


and dark glasses or- 


improving under 


an obstetric phy- 




the menstrual periods, 


dered. 


treatment. 


sician, nothing 




which are prolonged, with 






abnormal was 




somewhat excessive dis- 






found in the pel- 




charge. No other history 






vic organs. 




to be obtained. 










Said to have been affected 


Eye removed. 




The changes in the 




from birth. No history 






cornea w ere 




of causation could be ob- 






secondary to the 




tained. 






cyclitis. The spaces 
in the suspensory 
ligament were con- 
siderably obstruct- 
ed, it having very 
much the appear- 
ance of a mem- 
brane. Specimen, 
Fig. 6. 




Supposed to have been per- 


Atropine and bandage. 


# , 


No F.B. found. 




forated by steel fragment. 


Eye removed 19 days 




Specimen, Fig. 5. 




Iritis 3 days later. 


after injury. 








Eye was struck by a piece 


Eye removed. 




Appearances men- 




of stone. 






tioned in Group II. 
below. Specimen, 
Fig. 4. 



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Examination of Eyes after Removal. 

General Characters. 

Group I. Here the anterior chamber is shallow, the 
lens and iris are pushed forwards, and the pupil is dilated. 
In most cases the iris is adherent to the cornea for a 
greater or less distance at the periphery. In the earlier 
stage of the disease the circumlental space is somewhat 
diminished by swelling of the ciliary processes, but later 
on it is again increased, owing to the atrophy of the 
processes from the rise of intra-ocular tension. 

The aqueous and vitreous chambers contain an albu- 
minous fluid which is coagulated by the ordinary hardening 
reagents, and can be recognised from the fact of its taking 
a deeper stain with eosin than does the celloidin in which 
the specimen is embedded. 

On microscopic examination, the swelling of the ciliary 
body and processes is seen to be due to injection of their 
vessels, with exudation of lymph and leucocytes. There 
is also great proliferation of the epithelial cells, not only 
of the pars ciliaris retinae, but of the hexagonal pigment 
layer beneath, many of them being shed and, together 
with leucocytes, found loose in the vitreous chamber 
(Fig. 1). The dulness of the media and opacities in the 




Fig. 1. 



vitreous observed clinically are, no doubt, due to these, 
together with the exuded lymph. 

On looking: at the suspensory ligament it can be eceii 

i r i - i t i n Heated by VjOQQLC . 

that many of these epithelial cells, and some oiHthe leu< <>- 



cytes, having been carried forward with the lymph stream, 
have become entangled in the meshwork between the 
fibres constituting that structure. In consequence, addi- 
tional obstruction has been caused to the exit of the intra- 
ocular fluid from the vitreous into the posterior chamber, 
through the already diminished circumlental space (Fig. 2). 







* 







Fig. 2. 

The tension in the vitreous chamber has then evidently 
risen, and the lens been pushed forwards, and subsequent 
events have taken place as in ordinary primary glaucoma. 
It will be evident that the process would be exaggerated, 
and also more rapid, if, at the same time, there were an 
increase in the volume of intra-ocular fluid secreted. 

Group II. In this group the chief cause which leads to 
all the other anatomical differences is, that there is either 
very little or no proliferation of the epithelium on the 
ciliary processes. Consequently the only solid bodies 
thrown into the lymph stream through the vitreous are 
leucocytes, and these can readily pass through the meshes 
of the suspensory ligament under ordinary conditions. 
At times, however, even these are stopped, as may be seen 
in Fig. 3. These and other inflammatory products reach 
the posterior chamber*, and are carried thence through the 
pupil into the anterior chamber. Here many of them 
being washed against the posterior surface of the cornea, 
and being more or less sticky, either from their own 
natural property or from the accompanying albuminous 
exudation, adhere, and one having become ed "d&acSSf 




Fie 



others are attracted to adhere to it, and so little isolated 
heaps are formed and not a contiuuous sheet. These give 
rise to the dotted opacities on the cornea (Fig, 4). 




Fig. 4. 

By far the greater number of the leucocytes, however, 
are carried on in the lymph stream towards the angle of 
the anterior chamber, and here some of them may pass 
through the spaces of Fontana in the ligamentum pecti- 
natum, and so get removed. But many of them do not 

ape, but becoming entangled in this filter, whose 
meshes are much finer than those of the suspensory 
ligament, cause a gradually increasing obstruction, accom- 
panied by inflammation in that neighbourhood j(Fig- 5). 
This inflammation I regard as an entirely secondary pro- 



S, and think that the absence of circumcorneal injection 
in the earliest stages of the disease, even when punctate 
deposits on the back of the cornea are manifest) bears out 




Fig. 5. 

this point (vide Cases 14 and 15). In this connection I 
would draw attention to the fact that whilst the ciliary 
body and processes are supplied by the posterior or large 
ciliary arteries, the ligamentum pectinatum and sclero- 
corneal junction receive the greater part of their blood 
from the anterior ciliary arteries. 

The primary obstruction occurring here at the outlet 
of the anterior chamber, pressure is exerted on all sides of 
that cavity, and so the iris and lens are thrust backwards, 
the angle is widened, and the whole chamber increased in 
depth. 

Pigmented cells may occasionally be found in the de- 
posits on the back of the cornea, these may be small ones 
that have passed through the meshes of the suspensory 
ligament, or may be derived from the anterior part of the 
ciliary body which lies in the posterior chamber^ JThetv. 

i 1 i , . -, , Hosted by V-jCTDVlC 

are, however, never abundant si t ice, as I have said above, 



in this group of cases there is very little proliferation oi 
epithelium. 

In group I. where the primary obstruction i^ at the 
suspensory ligament, leucocytes ean at first pass through 
that structure, and some of these adhering to the back of 
the cornea give rise to small masses just as in the second 
group ; but these masses are never so large as those 
which occur in the latter, where the primary obstruction 
is in the spaces of Fontana, and where the anterior chamber 
is deep. 

In the examination of an eye that has been blind for 
some time from secondary glaucoma of the kind spoken 
of in Group I, it is at first rather difficult to trace the 
sequence of events, as the lens and suspensory ligament 
are frequently in their normal situation. This I consider 
to be due to the following circumstances. The lens and 
iris are at first pushed forwards, and the iris becomes con- 
gested and adheres to the cornea at its periphery, ob- 
literating the angle of the anterior chamber, thus shifting 
the locus of the obstruction more forwards. After the 
tension has been raised for some time, atrophy of the 
riliary processes takes place, and the circumlental spare 
is increased, and so the causes working at the original 
site of obstruction are diminished. In consequence the 




Fig. 6. 



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accumulation of pressure occurs as in group II. in the 
anterior chamber ; hut the adhesion of the iris to the 
cornea prevents the former structure being thrust back 
again and the anterior chamber deepened, therefore the 
lens is pushed back by itself to its original situation, and 
we have as a result, a deep posterior and shallow anterior 
chamber as is shown in Fig. 6. In some instances too, 
where the iris has not been firmly adherent all round, the 
irido-corneal angle may be seen to have been re-opened in 
places. This fact is proved by the angular shape of the 
iris section. In other instances, as in Fig. 7, the anterior 




Fig. 7 



chamber becomes deepened, although the iris is still ad- 
herent at the extreme periphery, and the angle effectually 
occluded. "The deepening of the posterior chamber and 
recession of the lens are also conduced to by the diminu- 
tion of secretion following atrophy of the ciliary processes 
and compression of the retinal vessels and consequent 
Lowering of tension in the vitreous chamber. 

Though spine authors distinguish between the cyclitis 
which is serous, and that in which the exudaffi!i by is plastic, 



no distinct line can be drawn between the two, as in all 
cases in which the disease has persisted for a time the 
exuded fluid becomes plastic, even though it were partly 
serous at first. Cyclitis in this respect follows the same 
course as iritis. 

Most of the later anatomical changes in the eye in 
this disease are due to this fact. It is owing to* the 
contraction of this plastic material that another alter- 
ation in the anterior chamber occurs in* old standing 
cases of Group II. This newly organising tissue is chiefly 
found in the circumlental space, and fco on contraction 
draws the root of the iris backwards, and laterally widens 
the anterior chamber ; and being attached to the peri- 
phery of the retina behind, detaches that structure in a 
circular fold at the ora serrata (Figs, 6 a, I 8 ). Probably 




Fig. 8. 



tins contraction too in Group L is instrumental in the 
retraction of the lens and deepening of the posterior 
chamber before mentioned. 

I have said very little about the increased secretion of 
intra-ocular fluid which occurs in the earlier stages of 
this disease, accompanied by changes ^ ed ^^^M^ body 
and processes, and this no doubt has a great causative 



SEROUS CYCLITIS. 255 

influence in the variations of tension noted from time to 
time ; but, as may be seen from what has been described 
above, it is only one factor in the chain of processes tending 
to the common end — glaucoma. 

With regard to the collections of leucocytes and lymph 
on the posterior surface of the cornea, changes may occur 
in the cubical endothelium between them and Descemet's 
membrane, as has been pointed out by many observers,*' 
but it is not the rule, and this layer is normal at the com- 
mencement of the deposit, and is still healthy if the 
deposit be early washed away as these observers main- 
tain, and the cornea may even in the most marked cases 
become eventually quite clear. 

H. Snellenf describes these masses as being chiefly 
composed of colonies of short bacteria, and speaks of the 
inflammation of the uveal tract as being secondarily 
caused by the toxines produced by these micro-organisms, 
though it is difficult to understand how these get into the 
anterior chamber of the unwounded eye, if not by the 
natural way of the secretion of intra-ocular fluid from the 
ciliary body, &o. 

I have attempted to make several cultivations from 
the fluid of the anterior chamber in cases that were being 
operated upon, but with negative results on each occasion. 

BraileyJ and others have described specimens of 
cyclitis with a large pigmented mass of exudation on the 
vitreous surface of the ciliary body. Sections of one of 
my specimens showed a similar nodule due to a remark- 
ably increased proliferation and accumulation of the pig- 
mented epithelial cells at that spot, which microscopically 
might have been taken for one of the melanotic neoplasms 
that sometimes occur in this neighbourhood. Treacher 
Collins§ has pointed out that this, occurring as it does all 

* Fuclis, Lawford, and others, 
f Vide Ref. 

X Trans. Oph. Soc, vol. ii, 16S2. 
8 Vide Kef. 



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round the ciliary region at the junction of the plicated 
and non-plicated part of the ciliary processes, is due to 
hypertrophy of the glands that he has described in that 
situation. The appearances on careful examination en- 
tirely coincide with such a hypothesis. 

In all the cases of long standing that I examined, 
various degenerative processes had occurred in both the 
cornea and lens, rendering them more or less opaque. 
Some of these Avere of a very interesting nature, but were 
of forms not limited to this disease alone. 

Treatment. — It is beyond the scope of this paper to 
enter fully into the subject of treatment, but the follow- 
ing points may be mentioned. 

From a consideration of the causes of obstruction it- 
will be obvious that, except perhaps now and then in 
cases of Group I, removal of a larger or smaller segment 
of the iris in the operation of iridectomy would be of no 
avail, either to stay the progress of the inflammation or to 
permanently reduce the intra-ocular tension ; and in fact 
in coneequence of the organisation of inflammatory pro- 




Fio. 9. 



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SEROUS CYCLITIS. 257 

ducts near the irido corneal angle in the process of repair, 
more obstruction may be caused and so the condition 
rendered worse. Another danger after iridectomy is from 
the blocking of the spaces of Fontana by pigmented epi- 
thelial cells of. the iris which may proliferate at the site 
of section and be set free. (Fig. 9.) 

Paracentesis, — Lt seems reasonable to suppose that the 
reduction of tension can best be effected by repeated 
paracentesis of the anterior chamber, so evacuating in- 
flammatory products with the intra-ocular fluid. Prob- 
ably the paracentesis should be done in front of, rather 
than in the sclero-corneal junction, so avoiding the exten- 
sion of the inflammation at the site of the puncture to a 
part already damaged. The operation with proper pre- 
cautions is quite free from danger. An objection to para- 
centesis* in normal eyes is that the aqueous humour 
secreted immediately after puncture contains coagulable 
material ; but that fact is of comparatively little im- 
portance in this disease, where the intra-ocular fluid is 
previously of that nature. 

It also seems clear that in some cases, the use of 
eserine is indicated, as for instance in the early stage of 
those in which the original obstruction is in the circum- 
lental space ; but it should not be persisted in if there be 
signs of the inflammatory process spreading to the his, 
and it must be remembered that this drug produces con- 
gestion of the ciliary processes. 

In the cases in which the anterior chamber is deep, a 
weak mydriatic (Atropine gr. \ to ^ j., or even less) may 
be circumspectly used, a careful watch being kept upon 
the tension. The objects of this treatment being to 
paralyse the ciliary muscle and to dilate the pupil and 
prevent the formation of posterior synechia?.. I have 
seen exclusion of the pupil and "irisbombe '' result in one 
case in which this had not been done. 

The main essentials in treatment are to give as com- 

* E. Graf, vide Ref. 



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258 SEROUS CYCLTTIS. 

plete rest as possible, e.g., dark glasses, and the avoidance 
of near work, combined with attention to any general 
disease concerned in the causation. 

The prognosis, unfortunately, at present is bad, owing 
to the great tendency to recurrence, and in nearly every 
case the vision is permanently damaged to a greater or 
less degree. 

I desire to express my thanks to Messrs. Couper, 
Tweedy, Nettleship, Lang, Silcock, Morton, Hodges, 
Kenneth Campbell, and Haydon, to whom I am indebted 
for permission to examine and refer to cases, and to Mr. 
Devereux Marshall, for "great assistance in the photo- 
graphy of the specimens. 

Description of Figures. 

1. Ciliary processes, showing proliferation and shedding of pigmented cells. 

i in. obj. 

2. Spaces in the suspensory ligament blocked by pigmented cells and leuco- 

cytes, i in. obj. 

3. Spaces in suspensory ligament blocked by leucocytes chiefly. Ciliary 

processes swollen, i in. obj. 

4. Rounded masses on posterior surface of cornea. £ in. obj. 

5. Spaces of Fontaua blocked by leucocytes, i in. obj. 

6. Lens retracted to normal position in later stage. Detachment of retina 

in fold. 2 in. obj. 

7. Partial adbesion of root of iris, deepening of anterior chamber later. 

i in. obj. 

8. Detachment of retina in folds at ora s errata. -£- in. obj. 

9. Spaces of Fontana blocked by pigmented epithelial cells from the iris 

after iridectomy, i in. obj. 



Literature. 



For an account of the literature on this subject, and 
the opinions of some former authors, I would refer to Mr. 
Lawford's paper in the Ophthalmic Hospital .Reports for 
1889, p. 298, et seq. 

The following more recent papers maybe consulted : 

Bjrailey. " Gouty Cyclitis." Trans. Ophtli. Soc, 1890, 
vol. x, 98—101. 



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SEROUS CYCLITIS. 259 

Trousseau, A. " Iritis Catameniale." Archiv. de tocol 

Paris, 1890, vol. xvii. 34,5—358. 
Kipp, C. J. " On Gonorrhceic Irido- choroiditis." Med. Leo. 

N.Y-, 1890, vol. xxxviii, 39—41. 
Bajardi. " Clin. Note on Irido-choroiditis following Menin- 
gitis and Influenza." Policlinico Torino, 1890, vol. i, 

264—272. 
Gowers. Medical Ophthalmoscopy, 1890, p. 196, mentions 

two cases of cyclitis connected with uterine disturbance. 
Grandclement. " Uveite Irienne." Rec. d'Ophth., Paris, 

1891, 3 s., vol. xiii, 257—260. 
Puech, A. " Some Indications for Paracentesis in Acute 

Iritis." Rec. d'Ophth., Paris, 1891, vol. xii, 1—13. 
Hutchinson, J. " Ophthalmitis after Parturition." Arch. 

Surg., 1890-91, vol. ii, 358—360. 
Collins, Treacher. " Glands of the Ciliary Body." Trans. 

Ophth. Soc, 1891, vol. xi. 
Knies Max. " Cyclitis." Grundriss der Angenh., 1892, 

vol. viii, 215. 
Greef, R. " Bact. Res. on origin of Symp. Ophth." Trans- 
lated in Randolph Arch. Ophth., N.Y., 1893, vol. xxii, 

298—312. 
Gagarin, N. W. " Case of essential Phthisis Bulbi." Clin. 

Monats. f. Augenh., Stuttgart, 1893, vol. xxxi, 251 — 

261. 

Saulat, A. " Case of Catamenial Iritis." Rec. d'Ophth., 

Paris, 1893, 3 s., vol. xv., 460—471. 
I . . . 

( Snellen, H., junr. " Over de oetiologie vom Deseemetitis." 

Translation, Ophth. Rev., Aug., 1894, 259—262. 
Stricker, L. " Syphilis of Uveal Tract." Cincin. Lancet 

Clinic, 1894, N.S, vol. xxxii, 143—149. 
Greef, R. "Befund am Corp. Ciliare nach Punction der 

vorderen Rammer." Arch. f. Augenh., Wiesb., 1893-94 

vol. xxviii, 178—192. 
Trousseau, A. " Iritis et Irido -cyclitis Infectienses." Ann. 

d'Ocul., Paris, 1894, vol. cxi, 199—205. 
Collins, Treacher. "Lectures on Anatomy and Pathology 

of the Eye at the Royal College of Surgeons." Lancet, 

Dec, 1894. 

VOL. XIV. S 



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260 



TWO CASES OF HEREDITARY CONGENITAL N1G-HT- 
BLINDNESS. 

By W. Til ling hast Atwool, 

Oplithalmic Surgeon to the Torbay Hospital ; late Olinical 

Assistant, Royal London Ophthalmic Hospital. 

Case 1. — Mr. H., a young nian 3 has never been able to see 
his way clearly at night. When going out after dark he has 
to exercise great caution in order to avoid knocking against 
other people, and objects in his path. He says that this pecu- 
liarity has existed in different members of his family for at 
least three generations. Patient has two sisters and two aunts 
who are night-blind. Both his father and grandfather were 
similarly affected, and the former, who was a naval officer, on 
more than one occasion accidentally walked overboard from 
the bridge at night. 




Several others, 
all u/ilA <yood stg/i/. 





Pal tent Palienl 
Case ff Case I 

Representation of the heredity in a family in tvbieh night-blindness occurs. 
M. male; E. female. The dotted circles indicate night-blindness. 

Patient's vision is 6/6 in each eye, and accommodation is 
normal. The visual fields are fully normal, both for white and 



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HEREDITARY CONGENITAL NIGHT-BLINDNESS. 261 

colours, when taken by diffuse daylight ; on lowering the illumi- 
nation they are very much contracted. 

Direct vision, however, does not appear to be excessively 
diminished on lowering the illumination, the diminution vary- 
ing in much the same ratio as the author's under similar con- 
ditions. 

Appreciation and discrimination of colour are perfect. 

With the ophthalmoscope there is nothing abnormal to be 
seen. There is physiological cupping of the discs, and pulsa- 
tion can be seen in some of the retinal veins. 

Patient's hair is black ; his irides dark brown. 

Case 2. — Miss H. is a hospital nurse, and sister of the above. 
She complains of the same difficulty of seeing in a bad light, 
insomuch that she is afraid to venture out of doors alone after 
dusk. 

The right eye was operated upon for internal strabismus 
some years ago. 

On examination she was found to be hypermetropic ; the 
vision with black types being — 

R. Y. = 6/18 ; c + 1-5 D. sph. = 6/12. 

L. V. = 6/6 ; o + 1 D. sph. == 6/6. 

With Bjerrum's grey types, No. 1 — 

R. V. = 6/60; L. Y. = 6/12 iii (normal = 6/9). 

With grey types, IJo. 2 — 

R. Y. <6/60; L. Y. = 6/12 ii (normal = 6/12). 

The visual fields are quite normal, except that those for 
green are very slightly and uniformly contracted. 

Appreciation and discrimination of colour are perfect. 

On ophthalmoscopic examination the pupils were active, the 
media clear, the discs and retinal vessels quite normal. The 
ground of the fundus was dark, and looked granular, but there 
was no pigment to be found in the retina, neither were there 
any white spots to be seen either at the macula or elsewhere, 
such as Mr. Nettleship describes in some of his cases. The 
choroidal vessels were very apparent. 

The first patient is somewhat deaf hi his right ear, a 
condition which becomes greatly aggravated when he 
takes cold. The deafness has existed for some years, but 

s 2 



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262 HEREDITARY CONGENITAL NIGHT-BLINDNESS. 

was not congenital, and appears to be merely secondary 
to a throat affection. The second patient had no defect 
of hearing. 

In neither of these cases is there any nystagmus, as 
has been shown to exist in some previously recorded cases. 

On comparing the family history with that given in 
other instances, it will be seen that there is no definite 
plan of heredity. For instance, in Mr. Nettleship's cases 
it was only the males who were affected, and they in- 
herited the condition through their mothers. In Mr. 
Morton's cases also atavism was marked, and no females 
were affected. Mr. Morton's patients had contracted 
visual fields, and he also noted that they were all fair- 
haired. In both of my patients the hair is dark, and, as 
has been stated above, there is no lack of pigment in any 
part of the uveal tract. There is no history of further 
deterioration in the defective vision of any member of the 
family to which my patients belong. 

The following is a list of some of the previously 
recorded cases, for which, together with the notes of the 
examination of Case II, I have to thank my friend Mr. N. 
C. Ridley. 

Cunier, F. Hist, d'une hemeralopie lierecl. clepnis deux 
siecles. Ann. Soc. de Med. de Grand, 1838, vol. iv, 
385—395. 

Chibret. Un cas extraordinaire d' hemeralopie congenitale. 
Arch. d'Ophth., Paris, 1884, vol. iv, 79—83. 

Fitzgerald, C. E. Case of congenital nyctalopia. Irish 
Hosp. Gaz., Dublin, 1873, vol. i, 216—218. 

Leber. Paper in Graefe u. Saemisch Archiv., vol. v, 648. 

Morton, A. Stanford. Two cases of hereditary congenital 
night- blindness without visible fundus change. Trans. 
Ophth. Soc, London, 1893, vol. xiii, 147—150. 

tnettleship, E. Clinical lectures on various kinds of ambly- 
opia. Oph. Hosp. Rep , 1 887, vol. xi, 368 et seq. 

Ovelgun, R. F. Nyctalopia hereditaria. Acta Acad. Nat. 
Curios. Norimb., 1744, vol. vii, 76, 



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HEREDITARY CONGENITAL NIGHT-BLINDNESS. 263 

Pagenstecher, H. Heraeralopia hereditaria. Period, de 

Oph. prat., Lisbon, 1880, vol. ii, JN"o. 1, 30. 
Peluger. Stammbauni einer Familie in welclier Hemeralopie 

neben hocbgradiger Myopiesich forterbt. Univ. Augen- 

klin. in Bern (1881), 1883, 54—59. 
Stieyenart. Note sur une hemeralopie hereditaire. Ann. 

d'Oculistique, Brux., 1847, vol. xviii, 163. 
Sedan. Une famille d'hemeralopes. Bee. d'Ophth., Paris, 

1885, 3 s., vol. vii, 675—678. 
Svvanzt. Cases of congenital hemeralopia. Irish Hosp. 

Gaz., Dablin, 1873, vol. i, 84—86. 
Thomas, L. Hemeralop. congen. idiop. Rec. de trav. Soc. 

Med. d'Indre et Loire, 1872, Tours, 1873, 87—90. 
Yieusse. Une nouvelle forme d 'hemeralopie dite hemeral. 

congen. ternporaire. Gaz. hebdora. de Med., Paris, 1878, 

2 s., vol. xv, 667—669. 
Zimmermann. Case of night-blindness, affecting four chil- 
dren of the same family. . Arch. Ophth., N.Y., 1883, 

vol. xii, 190—200. 

Note. — It can hardly fail to strike anyone reading the above 
list, that the words nyctalopia and hemeralopia appear to be 
used almost indiscriminately by different authors, with the 
same meaning — night-blindness. I have myself avoided the 
use of either term, but I should like to refer those interested 
in the point to two papers in these Reports, by W. A. Greenhill 
and J. Tweedy respectively, entitled u On the Meaning of the 
Words Nyctalopia and Hemeralopia," Ophth, Hosp. Reports, 
vol. x, 284—292 and 4L) — 436. 



\ 



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1 



264 



NOTES OF A CASE OE THROMBOSIS OE THE CENTRAL 
ARTERY OF THE RETINA, WITH ACUTE G-LAUCOMA AS 
A SEQUEL. 

By N. C. Ridley, late Acting Curator, R.L.O.H. 

Gr. P., aged 57, a strong healthy-looking man, who had 
recently completed 40 years' service in the Royal Navy, first 
came under my observation on February 19, 1895, complaining 
of pain and loss of vision in the left eye. 

The history of the present affection was somewhat indefinite, 
but he stated that to the best of his knowledge up to two 
months previously both eyes were well, although the right was 
always stronger than the left. At that time he one day felt a 
sudden attack of pain in the left eye, which he described as of a 
pricking character, as though he had some sand in it, and then 
found that the vision was much worse than that of the right. 
He, however, did not trouble himself about the matter, nor seek 
advice at the time. He noticed that the vision gradually 
became worse, and so at last he came to see me to inquire if 
anything could be done for it. 

Previous History. — The patient said that he never had any 
illness in his life, except that 15 years ago he was laid up for 
three weeks, after falling over a cliff one dark night when on 
coastguard duty. He served 10 years in China. No history of 
syphilis could be obtained. He was always a temperate man. 

General Condition. — Patient a stout man, but said that he 
had lately lost flesh considerably. 

Chest emphysematous. Costal angle wide. Breathing 
abdominal. 

Pulse 84. About every five or six beats there was a slight 
irregularity, and occasionally an intermission of one beat. 
Artery large, full between the beats, and difficult to compress. 
Not tortuous. 

Temporal arteries tortuous, uniformly large and hard. 

Heart : First sound rather short, aortic second sound 
accentuated. No murmurs. Emphysema masked the size of 
heart. 

Urine: No trace of albumin was found. 



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THROMBOSIS OF CENTRAL ARTETIY OF THE RETINA. 265 

Condition of Eyes.—R. V. = 6/18 1., c + 2'5 D. sph. = 6/9 ; 
c + 5-5 D. sph. = J 1. at 10". 

L. V. = shadows only. 

There was outwardly no difference between the appearance 
of the two eyes. The tension of each was normal. Both 
cornese were clear, there was do circumcorneal injection, the 
anterior chambers were of normal depth, the irides were bright 
and of the same colour, the pupils, of ordinary size and equal, 
and both reacted to light and accommodation. The reaction of 
the left one, however, was somewhat sluggish as compared with 
that of the right. 

Both lenses were transparent. 

With the ophthalmoscope nothing abnormal was found in 
the right eye. 

In the left the vitreous was seen to be fluid and to contain 
many fine floating opacities, which caused considerable obscura- 
tion of the fundus. The latter was of a uniform greyish-red 
colour; the whole of the vessels were minutely contracted and 
thread-like, with the exception of the superior temporal vein, 
which was much distended. There was no difference between 
the colour of the macula and that of surrounding parts. The 
disc was not cupped, but was pale and its edges indistinct. 

Embolism of the central artery of the retina was diagnosed. 
A few drops of a 1 per cent, solution of homatropine were 
instilled, in order to make a more thorough examination. No 
increase of pain was noticed at the time, but before the patient 
was sent away, a couple of drops of a 0*5 per cent, solution of 
eserinewere instilled for the purpose of counteracting the effect 
of the homatropine. 

Simple fomentations of boracic acid lotion were ordered, 
and the patient told to come again in a week's time. 

Four days later he returned, saying that the pain had been 
much worse, and had prevented him from sleeping-, and on 
inquiry I ascertained that he had vomited on. one or two occa- 
sions. Still, when asked about it, he insisted that the pain was 
" not very bad, not more than he could stand," and said be 
came to show me his eye because his doctor " did not like the 
look of it." 

He described the pain still as of a pricking character, and said 
it extended over the left brow, temple, and cheek. 



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2G6 NOTES OF A CASE OF THROMBOSIS OF 

There was diffuse sub conjunctival eechymosis, some slight 
haze of cornea and aqueous humour, a moderately dilated pupil, 
a somewhat shallowed anterior chamber, and a decided increase 
of intra-ocnlar tension. He could still see shadows with the left 
eye. The right field of vision was normal ; the left could not be 
definitely taken, but it appeared to be only moderately and 
uniformly contracted. 

On finding matters in this condition, T instilled some more 
eserine, and advised the patient to have an iridectomy per- 
formed at once. He said, however, that he would prefer to talk 
it over with his wife first, and would come and let me know his 
decision on the following day. In the meantime I prescribed — 

Jk Eserin. sulph. gr. ij, 

Cocain. hydrochlor. gr. V, 

Aq. distil ad. Jj, 
M. Ft. Gutt. To be used 3 times a day. 

Three days later, in the afternoon, he came again and said 
that he would have the operation performed, although the drops 
had given him considerable relief. 

On the next morning, therefore, as the root of the iris did 
not seem to be pressed against the cornea more at any one 
part than another, I did an iridectomy upwards, removing 
about one-fourth of the circumference of the iris by the com- 
bined cutting and tearing method. For this purpose chloro- 
form was administered, and the conjunctival sac washed out 
with warm boracic acid lotion. There was rather a severe 
attack of retching and coughing during the process of recovery 
from the anaesthetic. 

On the following day everything was quiet, and the patient 
said he had had the best night that he had experienced for a 
fortnight, and that there was no pain at all. Simple antiseptic 
dressings were applied, and the patient kept in bed for the next 
week, when all was healed up and quite quiet, the intra-ocular 
tension being normal. Vision was " shadows " as before. 

He was then allowed to get up, and two days afterwards I 
found that unfortunately the pain and tension had returned, 
and there was some hyphgerna. Paracentesis of the anterior 
chamber was at once performed, and again all went well, and 
the patient returned to his home. 



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THE CENTRAL ARTERY OF THE RETIVA, ETC. 207 

During the next three weeks, however, attacks of pain with 
increased tension and hyphema kept recurring, which were 
only partially relieved by paracentesis, &c. ; and as the vision 
was then reduced to merely perception of light, and the patient 
wished to have it done, the eye was removed on March 28 by 
Mr. Tillinghast At wool, of Torquay. 

Patient took the anaesthetic badly, and there was very 
severe haemorrhage both at the time of the operation and on 
several occasions during the following six days. There was 
also extensive ecchymosis of the whole left side of the face. 

Mr. At wool very kindly sent me the eye in a 10 per cent, 
solution of formol, and reports that the patient has since been 
quite well. The vision in the right eye is precisely the same 
as before; the field is normal, and the only abnormality in the 
fundus is that there are two small red spots, apparently haemor- 
rhages, just below the inferior temporal vein. 

Pathological Condition. — The eye was normal in shape and 
size. T-f. An anteroposterior vertical section was made, 
passing behind between the entrance of the optic nerve and the 
yellow spot. The optic nerve and the retina of the yellow spot 
region were removed for separate microscopic examination. 

Macroscopic Examination. — The operation wound at the 
npper sclerocorneal junction was perfectly healed, the iris not 
being involved in any part. There were one or two scars of 
paracentesis wounds in the lower part of the cornea. The rest 
of the cornea was clear. The anterior chamber was moderately 
deep. The lens was in situ, and transparent. The four 
arteries emerging from the disc presented a very striking 
appearance, looking like strands of shiny white cotton, and 
seemed absolutely bloodless. The vitreous, which was fluid, 
escaped during the process of thawing the specimen, which had 
been frozen for the purpose of making the hemisection. It 
contained a little blood in the lower part. The retina was in 
situ. 

Microscopic Examination. — The cornea was normal, except 
that there was slight swelling of some of the cells of the surface 
epithelium. The scar at the upper sclero-corneal junction was 
well healed ; one in the lower part of the cornea contained some 
red blood corpuscles. 

The anterior chamber, though fairly deep, had its angles 



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partially occluded all round by adhesion of a small portion of 
the root of the iris to the cornea ; the spaces of Fontana were 
not, however, completely blocked, as the adhesion did not 
extend the whole length of the fibres of the ligamentum peeti- 
natnm. There was a little blood debris in the lower angle. 




Fig. 1. — The occupation of some of the spaces of Fontana by deeply stain- 
ing leucocytes is shown by the dark mass in the angle. 

The iris was excessively thinned at the part where adherent, 
and at the site of the iridectomy it had been torn through at 
this thin part instead of at its extreme root, as had been 
intended. At the edges of the coloboma it was more adherent 
to the cornea than elsewhere. There was no ectropion of uveal 
pigment. 




Fig. 2. — Section of irido-corneal angle at the site of the iridectomy. 

The ciliary body below was the seat of a large haemorrhage 
between the muscle and the pigment layer. There was no 
manifest abnormality in the choroid. 

The whole retina was much atrophied, but had not lost the 
differentiation of its layers. There was considerable distension 
of its lymph spaces, evidently from figjigp^CffOCPStc marked 
between the two nuclear layers. At the yellow spot region, 



however, there was a small area in which there was little or no 
oedema, and at the macula itself the small space between the 
two nuclear layers was filled by a granular material, with no 
lymph channels in its substance, the retinal arteries had 
immensely thickened walls and a correspondingly diminished 
lumen. The thickening did not appear to be limited to the 
intima, but the media and adventitia were also affected. In the 
lumen were several large irregular cells with well-stained 
nuclei, but there was no blood. Some of the retinal veins con- 
tained blood, others were empty. 




Fig. 3. — Section of retina showing great thickening of the walls of an artery. 

The optic disc was not cupped, except in a small degree at 
the centre, which was probably physiological. It was not 
swollen. The general structure of the optic nerve was normal, 
but on examining sections involving the vessels it was seen 
that the lumen of the central artery was occupied by a mass of 
organised material, whose constituent fibres were arranged in a 



$ 



Fig. 4.— The occluded artery is below, the engorged vein aboye. (This 
figure very inadequately represents the appearance of the section.) 

regular concentric manner. This mass extended backWTLRds^ftR 

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far as the cut end of the nerve (3 mm.), and forwards appeared 



270 NOTES OF A CASE OF THROMBOSIS OF 

to reach nearly to the disc, the posterior part, however, seemed 
to be much more dense than the anterior. In one or two of the 
sections small vessels containing red blood corpuscles could be 
seen in the substance of the plug. The mass did not entirely 
occlude the artery, a small space being left all round at the 
periphery ; but as there was no sign of blood here it was 
probably formed by shrinkage in the process of hardening the 
specimen. 

The central vein and its tributaries in the nerve were dis- 
tended with blood, and a great number of leucocytes could be 
seen outside the vessel, having evidently escaped by dia- 
pedesis. 

Remarks. — This case has seemed to me to be worthy of 
record, not merely on account of the unusual ocular 
lesions, but also because it is illustrative of the great help 
to be obtained in the diagnosis of some general diseases 
from the examination of the eyes. 

It is very rarely that one has an opportunity of ex- 
amining an eye removed during life, in which obstruction 
of the central artery of the retina has been diagnosed. 
Mr. Nettleship, in describing a case of his,* says he had 
only been able to find records of three such cases. 

In this case the question arises, " What relation did 
the glaucoma bear to the other lesion ?" I am inclined 
to think little or none, for it is by no means a common 
sequela in cases where there has been blocking of the 
central artery ; though it is certainly remarkable that in 
Mr. Nettleship's case glaucoma also followed, and was 
the reason for excision. 

My patient was over middle age, and was a hyper- 
metrope, both conditions predisposing to glaucoma, and 
from the condition of the root of the iris there had pro- 
bably been some trouble in the escape of the intra-ocular 
fluid, with temporary rise of tension on previous occasions. 
It is quite likely that this may have occurred and no 
notice have been taken of the circumstance, as the patient 

* Oplifch. Hosp. Rep., vol. viii, p. 9. 



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THE CENTRAL ARTERY OF THE RETINA, ETC. 271 

was the kind of man who would not complain of any pain 
unless it were very severe ; for even when he had acute 
glaucoma, with vomiting, &c, he insisted that the pain 
was a not more than he could stand." Again, he said 
that the left eye had for some time not been so good as 
the right, and attributed it to the fact that the latter got 
more exercise from using a telescope so much in his occu- 
pation. 

Then, the instillation of homatropine for the pur- 
pose of examination, in an eye in this condition of 
unstable equilibrium, although followed by eserine, was 
just sufficient to upset the balance of secretion and 
removal of fluid, and induce an attack of acute glau- 
coma. 

I do not think that the passive congestion which would 
result from thrombosis of the artery, although sufficient to 
cause oedema of the retina, could suffice of itself to start 
the glaucoma process. 

.Mr. Nettleship's patient was also a man over middle 
age, but it is not stated whether or not he was hyper- 
metropic, and he also had a mydriatic administered for 
purposes of examination. As it was in the days before 
either homatropine or cocaine was known, atropine was 
the drug used, and that necessarily would have had a 
much more powerful tendency to produce increased intra- 
ocular tension. 

The reasons I have for considering the case to be one 
of thrombosis rather thau embolism are : — 

1. The patient had no evidence of valvular lesion of 
the heart. 

2. The changes in the arterial walls were not those of 
atheroma, but were more of the nature of . arteritis 
obliterans, due to renal disease. 

3. The blood-flow through the arteries would, on 
account of the irregular heart and inelastic vessels, be 
variable, a circumstance that would be favourable to" 
thrombosis. 



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272 NOTES OF A CASE OF THROMBOSIS OF 

4. The gradual progression of the case ; for though the 
onset was sudden, the loss of vision was not at its maxi- 
mum at first, but gradually got worse. The fact that 
there was perception of light even to the end was pro- 
bably due to the establishment of some little collateral 
circulation, through the feeble anastomoses with the 
choroidal arteries near the disc, and at the ora serrata. 
Still, recovery of perception of light after a time is not 
uncommon in cases of embolism, even though it may have 
been absolutely lost at first. 

5. The obstruction was least marked at the bifurcation 
of the artery at the disc. Certainly, however, the throm- 
bus might possibly have been secondary to an embolus at 
the origin of the central artery of retina from the ophthal- 
mic, the other branches of the latter vessel receiving 
blood through their anastomoses. This manifestly could 
not be ascertained in this case. 

6. The concentric arrangement of the constituents of 
the plug ; as though its formation had occurred after the 
manner of ante-mortem clots in the heart and large 
vessels. 

There was no sign in this patient of thrombosis of the 
internal carotid, or any cerebral artery, which Dr. Gowers 
remarks is a frequent concomitant of thrombosis in this- 
region.* 

Mr. Priestley Smith considers that many of the cases 
diagnosed as embolism of the central artery of retina 
are really cases of thrombosis, the ophthalmoscopic 
appearances being identical in both conditions.! 

Latest Report from Mr. Atwool, April 23, 1895. 

" There are now several small haemorrhages in the 
lower part of the right fundus, and a small patch of exuda- 
tion on the inner side of the disc. Disc not swollen, but 
its outline soft and indistinct. Patients general condition 

* Mod. Ophthalmoscopy, G-owers. Ed. Ill, 1890. 
f Ibid. 



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THE CENTRAL ARTERY OF THE RETINA, ETC. 273 

seems to be getting worse, the heart is more irregular, 
and on examination of the urine it is found to contain a 
considerable amount of albumin, the specific gravity 
being 1016." 

It appears probable, therefore, that the kidneys are 
failing in their function, either from an increase in the 
renal lesion, or from heart failure. 



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274 



ON THE RESULTS OBTAINED AETER THE EXTRACTION OF 
FOREIGN BODIES FROM THE EYE WITH THE ELECTRO- 
MAGNET. 

By H. Y. McKenzte, Junior Souse Surgeon, R.L.O.H. 

It has seemed to me that a paper on this subject might 
serve some useful purpose, chiefly because the measure 
of success which one may expect in the treatment of such 
cases is not fully appreciated. With the object of clear- 
ing up the difficulty which one experiences in giving a 
prognosis, I have collected a series of cases, in the hope 
that the results here obtained may be of assistance. 
Although the paper has been written for this main pur- 
pose, certain other interesting facts have been brought 
out, to which attention will be drawn. 

The cases have been collected from the in-patient 
records of this hospital, and extend over a period of six 
years, viz., 1889 — 1894. Great care has been taken to 
include only those cases in which a piece of steel or iron 
was actually present in the eye ; all doubtful cases have 
been ignored. The nature of the foreign body has been 
established either by its successful removal with the 
electro-magnet, or, in the few cases in which the latter 
failed, by the presence of the piece of metal in the globe 
after enucleation. 

The number of cases which have occurred in the 
above-mentioned period has been 50; in 10 of these the 
cornea or cornea and iris were wounded, in 12 the crystal- 
line lens was wounded without being penetrated, and in 
the remaining 28 the piece of metal had forced its way 
into the vitreous chamber with or without injury of the 
lens. We thus see that the commonest part in which the 
foreign body becomes embedded is the vitreous, in which 
situation it is more than twice as frequent as in any other, 
and, as we shall see later, this particular form of injury 
is by far the most disastrous. 



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EXTRACTION OF FOREIGN BODIES WITH THE MAGNET. 275 
The following is a table of the cases : — 





Cases. 


Per cent. 


'With wound of cornea, and iris 


10 
12 

28 


20 


,, ,, lens 


24 


„ )5 vitreous 


56 







Of these 50 cases the eye was saved in 30, or a per- 
centage of 60 ; lost in 20, or a percentage of 40. On a 
closer inspection of the cases, however, one finds that 
these figures are misleading ; they are too unfavourable 
for certain injuries, .e.g., injuries to cornea and lens, and 
much too favourable for those cases in which the foreign 
body was in the vitreous. This discrepancy is due to the 
fact that the situation of the chip of metal is the most 
important factor in determining whether surgical proce- 
dure will meet with success. It would thus seem that a 
more reliable criterion would be arrived at if one sub- 
divided the cases into three groups, according as to 
whether the foreign body were in the cornea or iris, lens, 
or vitreous chamber, 

I. Cas>e$ in which the Cornea and Iris were -alone wounded , tlie 
latter not being penetrated. 

Ten cases (Nos. 1 — 10) fall into this group for considera- 
tion ; their treatment is so eminently satisfactory that a 
discussion of them need not detain us. It might be well 
to mention that where the cornea alone was injured the 
foreign body had nevertheless penetrated so deeply into 
its substance that there was grave fear of perforation, with 
its attendant consequences, if the ordinary routine treat- 
ment of removal with a spud or needle had been resorted 
to ; hence their inclusion in this series. The piece of 
metal was successfully removed with the electro-magnet 
in every case without resulting impairment of vision, or, 
in other words, the percentage of successes was 100. 

VOL. XIV. T 



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276 RESULTS OBTAINED AFTER EXTRACTION OF FOREIGN 

II. Cases in which the Lens was injured hut not 'penetrated. 

The piece of metal must have struck the eye with 
greater force as compared with the injuries in the former 
group, and the damage to the ocular structures have 
necessarily been more severe. One would thus expect 
that any operative procedure would not meet with the 
same proportionate amount of success ; this is fully borne 
out by these results. Instead of all the cases being suc- 
cessful, only about three-fourths can be classed as such, 
and even among these there is a considerable number with 
distinctly defective vision. 

Twelve cases (Nos. 11 — 22) are to be considered. All 
were complicated by the formation of traumatic cataract ; 
in some the foreign body was lying in front of the lens, 
having wounded its anterior capsule ; in others, again, it 
was in the substance of the lens. The terminal of the 
electro-magnet failed to remove the piece of metal in one 
case (No. 14), which was ultimately lost ; the remaining 
11 were saved. There is unfortunately no note of vision 
in three of the cases; accordingly we are reduced to nine 
cases from which to calculate results. Of these, in three 
cases the vision was more than 6/18 and J. 1 ; in four 
others the vision was more than 6/60; in one the vision 
was reduced to the perception of light only; and the eye 
was removed in one case. 





Cases. 


Per 


cent. 


Vision 
■)■> 


me 
P. 


T, 


than 6/18 and J. 1 . . . . 




3 

4 
1 
1 


33 
44 
11 
11 


•33 


6/60, but less than 


6/18 .... 


•44 
•11 


Lost 








•11 














9 


99-99 



If one consider that persons whose vision was 6/60 
or more after the operation had been successfully treated, 



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BODIES FROM THE EYE WITH ELECTRO-MAGNET. 277 

there are seven such cases to record, or a percentage of 
77-77. Unsuccessful and lost cases each furnish one 
example, or a percentage of 11*11. 

III. Cases in which the Foreign Body toas in the Vitreous 
Chamber. 

If the piece of metal is in the vitreous, the general 
consensus of opinion that the prognosis is very grave is 
strengthened by the results in the following cases. When 
one considers the severity of the damage to the ocular 
tissues caused by the foreign body in its path to the 
vitreous chamber, and the fresh injury which must 
inevitably follow the introduction of the terminal of the 
electro-magnet, however skilful its manipulation may be f 
the wonder is that any eye should be saved and 
possess useful vision after removal of the chip of steel. 
And yet this is not all one has to contend with. The 
vitreous humour constitutes such a -perfect medium for the 
growth of micro-organisms that suppuration often rapidly 
supervenes on the injury, and even should the foreign 
body be not sufficiently septic to start this, the pro- 
lapse of vitreous which so frequently accompanies the 
injury may be, and often is, the starting point of sup- 
puration by direct infection from the conjunctival sac, 
Another factor, and it is no small one, whicli materially 
influences our results is that the electro-magnet is not 
always successful in withdrawing the foreign body, 
Indeed, it failed to remove the offending particle in quite 
a large proportion of the cases, viz., eight, or a percentage 
of 28-57. 

The number of successful eases in this group 
does not compare favourably with those in the pre- 
ceding, in which former three-fourths of them eould be 
safely classed as successful, whereas in this group only 
one-fourth can be said to fail into that category. 

An examination of the 28 cases elicits the fact that in 
20 the eye was lost, and in eight it was saved- 

T 2 



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278 RESULTS OBTAINED AFTER EXTRACTION OF FOREIGN 

The lost eyes are accounted for in the following man- 
ner. Nineteen of them were enucleated, and one though 
not excised had no perception of light. Of the former 
number, eight were removed as the electro-magnet had 
failed to withdraw the foreign body ; eight were removed 
on account of inflammatory changes involving the uveal 
tract, in four of which there were distinct signs of com- 
mencing suppuration. Two were removed for signs of 
sympathetic irritation in the opposite eye, and one was 
removed immediately the piece of metal was withdrawn, 
owing to the extensive disorganisation of the globe which 
had ensued. 

The remaining cases — eight in number — do not, unfor- 
tunately, all come up to the standard of what may be con- 
sidered successful ; in only three of the cases was the 
vision which was ultimately obtained useful. Of one 
there is no note of vision. There remain seven cases 
from which to draw our conclusions. Two of these 
retained vision equal to or more than 6/12 and J. 1, and 
in one the vision was 6/60. In two others the patient 
could only count fingers, and in the remaining two the 
vision was reduced to perception of light. 

I have tabulated the cases in this group as follows : — 





Cases. 


Per cent. 


V. = Ci/6 and J. 1 (]), 6/12 and J. 1 (1). Total == 
V — 6/60 


2 
1 
2 

2 


7-407 
3 703 


V. = Fingers at 5 ft. (1), at 3 ft. (1) 

V. = P. L. (one had old choroidal atrophy) 


7-407 

7-407 




7 


25-924 



On taking the standard of success to be the same as 
in preceding group we have : — 



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BODIES FROM THE EYE WITH ELECTRO-MAGNET. 



279 





Cases. 


Per cent. 


Successful 


3 

4 
20 


11-11 


Unsuccessful , 

Lost 


14-81 
74-07 








27 


99-99 



In conclusion I have to thank the Surgical Staff of 
this Hospital for their kindness in allowing me to make 
use of these cases. 



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280 



RESULTS OBTAINED AFTER EXTRACTION OF FOREIGN 



No. of 
case. 



No. in 
Hospital 
Register. 



10 
11 

12 



458 



1050 



1348 



1638 
943 

1518 
312 

223 



13 477 



Name. 



Sex. 



r. d. m 



J. B. 



E. S. 



1014 


a. a. 


1579 


E. W. 


1270 


Y.Q. 


1190 


A. J. 



J. K. 
A. T. 

W.N. 
J. L. 

J\D. 
F. 0. 



Age. 



Time that 

elapsed between 

accident and 

admission. 



21 3 weeks , 



30 

24 

16 
18 

20 

40 



1 day . 



4 days 



10 days , 

2 



34 2 „ 



20 

20 
21 

40 
33 



1 day . 



Same day . 
12 months . 



Nature of accident. 



F. B. deeply embedded in cornea « 



Small wound in lower third of 
cornea, and piece of steel sticking 
in lower part of iris, lens un- 
injured 

F. B. deeply embedded in cornea . . 



Small piece of steel in iris, corneal 
wound healed 

5 dayg F. B. deeply embedded in cornea . . 



6 weeks . 



1 day . . . 



Iris discoloured with rust-coloured 
plaque lying on it, lens uninjured 

On the posterior surface of the 
cornea is entangled a F. B., to 
which pupillary margin of iris is 
attached 

F. B. embedded in iris. Hypopyon 

Small yellow mass on iris at outer 
side, in which a F. B. is seen. 
Corneal wound healed, lens clear 

F. B. embedded in iris. Lens un- 
inj ured 

Lens quite opaque, embedded in 
its anterior capsule a piece o 
metal is seen. V. = fingers at 6' 

Lens opacity anterior and posterior 
chiefly, with chip of metal seen 
ia anterior cortex of lens. Iris 
uninjured. V. = 6/60. T. full 

F. B. in anterior capsule of lens, 
which is wounded and becoming 
opaque 



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BODIES FROM THE EYE WITH ELECTRO-MAGNET. 



281 



Operation. 


Secondary 
operations. 


Immediate 
vision. 


Remote 
vision. 


Remarks. 


Magnet applied directly over it, 
and piece of steel readily with- 
drawn 


•• 


6j6 J. 1 






Terminal of magnet introduced into 
corneal wound, and F. B. removed 


•• 


6/6 J. 1 






Magnet applied directly over it, &c. 
A. C. was opened 




6/60 J. 1. 

Refraction 

myopic 


-* 


An attempt with 
needle had 
failed. 


Corneal incision and removal 


•• 


"Good" 






Broad needle introduced into A. C. 
and placed behind .F. B. for sup- 
port, then removal with magnet 


•• 


6/12 J. 1 






Corneal incision over seat of F. B., 
&c. 


Division of an- 
terior synechia 

51 J) 


6/12 J". 1 
6/6 J. 1 






Corneal incision below, &c. Hypo- 
pyon evacuated 


•• 


6/9 J". 1 






Corneal incision, &c. . . 




6/12 J. 1 

6/18 J. 4. 
Hyp. ast. 






Wound enlarged, &c. ............ 


'• 










Iridectomy upwards, removal of 
F. B. with magnet, then extrac- 
tion 


•• 


•• 


6/24 


Some capsule 
present. 


Corneal incision and removal of 
F. B. readily 


Evacuation of 
lens matter 


6/24 J. 6 


'• 


Some capsule. 


Removal of F. B. through wound. . 


Partial evacua- 
tion of lens 
matter 


No note 


•• 


Much lens matter 
still present. 



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282 



KESULTS OBTAINED AFTER EXTRACTION OP FOREIGN 



No. of 
case. 


No. in 
Hospital 
Register. 


Name. 


Sex. 


Age. 


Time that 

elapsed between 

accident and 

admission. 


Nature of accident. 


14 • 


2266 


F. 0. 


M. 


24 


1 day 


Cornea and iris perforated, lens 
wounded 


15 


241 


A. S. 


»> 


23 


Same day .... 


Lens opaque, and lying transversely 
in it a metallic body 


16 


1867 


J". P. 


>) 


17 


1 month 


Lens partially opaque, and F. B. in 
it. V. = 6/36. 


17 


808 


C. H. 


j> 


24 


2 days 


Lens swelling and becoming opaque 
no F. B. seen 


18 


1320 


W.J. 


}) 


35 


2 „ 


Lens swollen, opaque, and bulging 
iris forwards. F. B. not seen. Nt 
reflex. V". - P. L. T - . 


19 


463 


a. h. 




21 


Same day 

4 years , 


Large F. B, lying in lens , 


20 


722 


T. E. 


i) 


50 


Lens quite opaque, lying in fronl 
of it is a piece of metal, V. = 
hand-movement. Tn. 


21 


838 


T. B. 


» 


28 


3 days 


Cornea and iris perforated, lens 
becoming opaque, F. B. not seen. 
Small hypopyon 


22 


1192 


T. P. 


3) 


34 


6 days 


Lens quite opaque. A. C. full of 
swollen lens matter. F. B. in 
lens. V. = P. L. Tn. 


23 


357 


gl S. 


>J 


23 


1 day 


Cornea, iris, and lens wounded. 
No F. B. seen 


24 


361 


A. 0. 


J3 


35 


Same day 


Cornea, iris, and lens injured, track 
through lens. No F, B. seen 


25 


168 


E. W. 


J3 


31 


)) • • • • ' 


Lens, &c, injured. F. B. seen in 
vitreous. V. = fingers. T. — 



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Operation. 



Secondary 
operations. 



Immediate 
vision. 



Remote 
vision. 



Remarks. 



Magnet unsuccessful . 



Wound enlarged and F. B. removed 
Corneal incision, &c 



Corneal incision and removal of 
F. B. from lens 

Corneal incision and removal of 
F. B. from lens. Curette evacua- 
tion 

Removal of F. B. through ground, 
some lens matter and vitreous 
escaped 

Iridectomy, removal of F. B., then 
scoop extraction of shrunken lens. 
No vitreous lost 

Iridectomy, removal of F. B., 
evacuation of lens matter 



[Removal of F. B. through enlarged 
wound. Curette evacuation. Some 
vitreous lost 



[Extraction with iridectomy, then 
terminal of magnet pushed into 
vitreous and F. B. removed. Some 
vitreous lost 

' Removal of F. B. from vitreous 
through original wound. Some 
vitreous lost 

Iridectomy. Scoop extraction. 
Magnet pushed into vitreous with 
no result 



Excision 



Evacuation of 
lens matter 

1 Extraction. 

2 Division of cap- 
sular synechia 

1 Needling. 

2 Lens evacuated 

Paracentesis per- 
formed three 
times 

Iridectomy and 
curette evacua- 
tion 



No note 



6/60 J. 16 



Hand- 
movement 



6/18 J. 1 



No note 



No note 



Excision. 



Excision. 



5/60 J. 18 



6/9 J. 1 



6/9 J. 1 



No P.L. 



F. B. in A. C. 



Capsule all over. 



Some capsule. 



Still much lens 
matter present. 

Fine capsule, 
vitreous opaci- 
ties. 



Remote V. taken 
11 months after 
operation. An- 
terior synechia 
otherwise nor- 
mal. 

Eye was suppu- 
rating. 



Six months after 
operation, eye 
shrunken, &c. 

F. B. in vitreous. 



_HostecM3^ 



Google 




Extraction of foreign 



No of 
case. 


No. in 
Hospital 
Register. 


Name. 


Sex. 


Age. 


Time that 

elapsed between 

accident and 

admission. 


— | 


26 1 


1383 


J. S. 


M. 


32 


Same day 


Cornea and lens injured. F. B. not 
seen. V. = hand 


27 


1127 


H. A. 


» 


21 


4 months 


Lens quite opaque. Y. = hand- 
movement. T. — 


28 


1789 


r. a. 


» 


36 


Same day 


Cornea, iris, and lens wounded. No 
F. B. seen 


29 


352 


F. M. 


)> 


38 


j> • • * . 


Small hole in cornea, iris, and 
posterior capsule of lens. F. B 
seen downwards ? V. = 6/6. 
T. - 


30 


1763 


S. W. 


J5 


25 


5) 


Large perforation in sclerotic on 
inner side of globe, with large 
F. B. in vitreous 


31 


864 


H. F. 


» 


50 


,, ..... 


Cornea and lens injured. Vitreous 
prolapsing. No F. B. seen. Y. = 
P. L. T. -3 


32 


1045 


S.J. 


" 


40 


8 days 


Corneal scar, wound of iris, opaque 
track through lens. Yitreous 
opacities. Y = 6/24. F. B. not 
seen 


33 


1188 


a. s. 


■)■) 


17 


Same day. .... 


Wound of cornea and iris. Lens 
becoming opaque. Yitreous opa- | 
cities. No F. B. seen. Y = I 
fingers at 7'. T - 3. 


34 


207 


a. b. 


» 


39 


>) 


Wound of cornea, iris, and vitreous 
prolapse, lens has escaped ? 


35 


1232 

! 


H. M. 

1 

i 


" 


17 


)> 


Penetrating wound of sclerotic, 
vitreous presenting, iris and lens 
uninjured. No F. B. seen. Y = 
6/12. T - 1. 

1 



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BODIES FROM THE E 



285 



Operation. 



Secondary 
operations. 



Immediate 
vision. 



Remote 
vision. 



Magnet introduced through, wound, 
and P. B. removed from vitreous. 
A good deal of lens matter and 
some vitreous escaped 

Extraction with iridectomy. Mag- 
net pushed into vitreous with, no 
result 

Removal through wound of a large 
F. B. from vitreous. Some lens 
matter and vitreous escaped 

Incision to outer side of inferior 
rectus tendon. Terminal of mag- 
net introduced, and F. B. re- 
moved from vitreous. (No note 
as to whether vitreous was lost.) 



Magnet removed F. B. 
cision 



Then ex- 



Removal of large F. B. through 
original wound from vitreous. 
Some vitreous lost 

Incision on outer side of inferior 
rectus tendon, magnet introduced, 
and F. B. removed ; very little 
vitreous lost 



Same as preceding ; no vitreous lost 



Removal of large F. B. by enlarg- 
ing wound. Iridectomy. Some 
vitreous lost 

I Magnet introduced on three sepa- 
rate occasions, with, no result 



Excision. 



6/12 



3/12 J". 1 



Excision. 



1 Needling five 
months later. 

2 Needling three 
months later. 
(Projection not 
good below) 



Excision. 



! 



6/60 



P. L. 



P. L. 



Excision. 



Remarks. 



Eye was suppu- 
rating. 



F. B. was lying 
behind ciliary 
body. 

Iridocyclitis. 



Remote V. was 
taken 11 months 
after operation. 
Opacity in lens 
capsule in at at a 
quo. 

Globe quite dis- 
organised. 



Iridocyclitis. 



Eye was suppu- 
rating. 



Old choroidal 
changes in 
fundus. 

Suppuration. 
F. B. was lying 
behind ciliary 
body. 



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TION OF FOREIGN 



No. of 
case. 



No. in 
Hospital 
Register. 



38 

37 

38 
3D 

40 

41 

42 
43 

44 

45 

40 
47 



Name. 



Sex. 



Age. 



Time that 

elapsed between 

accident and 

admission. 



1472 

1940 
167 
489 

625 

1728 

1577 
1726 

806 

730 

717 
1116 



E. 


L. 


A. 


M. 


A. 


E. 


E. 


F. 


W. 


W. 


H. 


C. 


A. 


P. 


W 


B. 


A. 


M. 


a. 


T. 


w. 


S. 



a. a. 



M. 



15 

20 
17 
21 

20 

28 

26 
21 

27 

46 

25 
34 



Same day. 



7 dajs 



11 days 



Same day. 



Nature of accident. 



Wound of cornea, iris, and lens 
Hypopyon. 



Wound of cornea, iris, and lens. 
No F. B. seen 

Wound of cornea and sclerotic. 
Iris and vitreous prolapse. Lens ? 

Wound of sclerotic just outside 
ciliary region 



Wound of sclerotic, lens uninjured. 
Large metallic body seen in lower 
part of fundus 

Wound of cornea, iris, and lens. 
No F. B. seen 



Wound of cornea and lens. 



Wound of cornea, iris, and lens. 
F. B. not seen 



Wound of cornea and iris. Lens 
quite opaque. Y. = P. L. T — 2 



Wound of cornea and lens. F. B. 
seen attached to posterior cap- 
sule of lens and reaching into j 
vitreous. Y. = fingers at 3'. T- 

Wound of cornea and lens. No j 
F. B. seen 



Wound of sclerotic far back. 
Yitreou? prejenting. F. B* not I 
seen 



I 



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BODIES FROM 



Operation. 



Secondary 
operations. 




Paracentesis and evacuation of 
hypopyon. Removal of large piece 
of steel from vitreous with, difh- 

l culty. Some vitreous lost 



Iridectomy, and magnet introduced 
■without result 



ay. Magnet introduced on 
icessive days. No result 



R miovai of large F. B. from vitreous 
through wound. Little vitreous 
lost 

Original wound enlarged and F. B. 
removed through it ; some vitreous 
lost 

laguet introduced through wound, 
sfo result 



asfnet introduced through wound, 
fo result 

lioval of large F. B. from 
reous through wound. Some 
|is matter and vitreous escaped 

lectomy. Scoop extraction. 
Imoval of F. B. from vitreous, 
ae vitreous lost 

ieetomy. Terminal of magnet 

produced behind lens and F. B. 

\ioved. Scoop extraction. 

j»ut one -fifth of vitreous lost 

fneal incision and removal of 
B. from vitreous with difn- 
Llty. Some vitreous lost 

■gnet introduced through wound. 
> result. Second attempt 
me days later with magnet suc- 

Ijsful, some vitreous lost 



Excision. 



Excision 



Immediate 
vision. 



Remote 
vision. 



1 Iridectomy. 

2 Excision 



Needling (four 
months later) 



1 Iridectomy. 

2 Excision 



Fingers at 
5' 



6/60 



No note 



Fingers at 

2' 



Fingers at 
3' 



He marks. 



6)6 all J. 1 
Huently 



Eye was shrink- 
ing. 



F.B. in vitreous. 



Suppuration. F. 
B. in vitreous. 

Vitreous opaci- 
ties, vacuoles 
in lens. 

Vitreous opaci- 
ties. Fundus 
normal. 

Suppuration. F. 
B. was lying at 
back of ciliary 
body. 

F. B. in vitreous. 



Eye was shrink- 
ing. 



"Has made good 
recovery." 



Sympathetic 
irritation. 



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Google 



-H 



:I0N OF FOREIGN 



No. of 
case. 


No. in 
Hospital 
Register. 


Name. 


Sex. 


Age. 


Time that 

elapsed between 

accident and 

admission. 


Nature of accident. J 


4-8 

49 
50 


1264 

69 
166 


H. F. 

G.D. 
J. H. 


M. 


20 

27 
47 


Same day .... 
1 day 

i 

i 


Wound of cornea and lens. No 
F. B. seen 

Wound of cornea, track throu 
. lens. No F. B. seen 

Wound of cornea, iris, ens. 
Most of lens has escaped ous 
presenting 



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■I 



Oases of Meningitis following Excision of the Eyeball. 



Condition of eye. 



uppurating after extrac- 
tion of Itpsule of trau- 
nmtic cajjaract caused 7 
years before by a gun 
cap. I 

ippuratin| after re- 
moval of| prolapsed iris 
after a p/'/^orated trau- 
matic ulgf ft Next day 
lens escajf ,3d, and vitre- 
ous prolf./osed. 

■ i 

r ound of (^ornoa, iris and 
lens. Hvphseilia lens 
or vitreous in wound. 
Eye suppurated in 2 
days, and patient re- 
fused excision until 20 
days later. 

oughing remains of 
globe. Cornea destroyed 
by ulceration. Pus in 
globe. 



7Q suppurated 
after removal 
cataract. 



7 days 
of the 



Complications at time 
of operation. 



Sclerotic wounded, and 
escape of pus into orbit. 



"None 



Eye adherent to orbital 
tissues. Pus e^oaped in- 
to orbit. Shrunken 
sclerotic, together with 
much adherent orbital 
fat removed. 



Contents of globe escaped 
into orbit. Nerve cut 
very close to globe; 
another piece afterwards 
removed. 

Globe ruptured, and some 
purulent matter escaped. 



Treatment of wound 
after operation. 



Irrigation with hyd. pcr- 
chlor. 1 - 3500. 



Irrigation with hyd. per- 
chlor. lotion 1 - 3500. 



Irrigation with hyd. per- 
chlor. lotion 1 — 4000. 



JLJCligL'JLl Oi 

time eye had 
been suppu- 
rating before 
excision. 



Socket not irrigated. Dry 
wool compress applied. 



Socket allowed to bleed 
freely for some minutes. 
Dry wool compress 
loosely applied. 



Lengtl 

time i. 

patient ] 

after sym 

develoj 



s 21 hours 



18 hoursl 



35 hours 




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f 



BODIES FROM THE EYE WITH ELECTRO-MAGNET. 



289 



Operation. 



Secondary 
operations. 



Magnet introduced through wound. 
No result. Some days later 
magnet successful. Iridectomy. 
Some vitreous lost 

Magnet introduced. No result .... 



Magnet introduced and large F. B. 
removed from vitreous 



Excision 



Immediate 
vision. 



Remote 
vision. 



Remarks. 



Sympathetic 
irritation. 



Suppuration. F. 
B. lying behind 
ciliary body. 

Suppuration. 



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Goo gle 



Ophthalmic Hospital Reports, 

Vol. XIV. Part II. December, 1896, 



A CASE OF SUBHYALOID HEMORRHAGE, IN WHICH THE 
SPECIMEN WAS OBTAINED WITH MICROSCOPIC SECTIONS. 

By J. Herbert Fisher, M.B., B.S. (Lond.). 

Cases of so-called subhyaloid hemorrhage have now been 
recorded more or less fully in considerable numbers, and 
ophthalmic surgeons are thoroughly familiar with their 
characteristic and striking clinical appearances. The exact 
source of this variety of intra-ocular haemorrhage and its 
anatomical situation are important points, however, on 
which no general consensus of opinion, I believe, exists 
up to the present, and I need, therefore, offer no apology 
for recording an interesting case of the .condition in ques- 
tion, in which an exceptional opportunity is afforded for 
studying the points in debate. The case was under the 
care of Mr. Lawford, at St. Thomas's Hospital, and I am 
greatly indebted to him for his permission to record it, as 
well as to Mr. Devereux Marshall, for his careful prepara- 
tion of the specimens obtained. I must also acknowledge 
the assistance I have had from Mr. Lawford, in looking up 
references, and in getting the microscopical sections so 
accurately drawn. 

Nettleship, in his work on Diseases of the Eye, refers 
to the condition under the head of Retinal Diseases 
VOL. xiv. u 



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2i)2 A CASE OF SUBHYALOID HEMORRHAGE. 

and on p. 210 attributes the phenomenon to rupture of a 
large retinal vessel, probably an artery, while on p. 204 
he is apparently referring to these cases, and states that 
probably all the retinal layers become infiltrated, while 
sometimes the anterior limiting membrane becomes 
ruptured, and the blood passes into the vitreous. ^ Com- 
menting on Stanford Morton's case, recorded in the 
Transactions of the Ophthalmological Society, vol. iv, 
Nettleship states his opinion that the arrangement of the 
retinal structures in the region of the macula accounts for 
hemorrhages of this character affecting that situation in 
preference to any other. 

Berry also describes subhyaloid hemorrhage under 
the head of Diseases of the Retina, cas an effusion of blood 
from the retina, which spreads out in a thin layer between 
the retina and the vitreous, without passing into the latter. 
He adds that persistence in some cases of the scotoma, 
always present in the early stages, is thought to be due 
to damage done in the laceration of the retina by the 
blood, and states that the exact pathology and explana- 
tion of the fairly constant situation of this variety of 
haemorrhage is unknown. Hotz, in the Annals of Ophthal- 
mology and Otology, 1893, on the other hand, argues 
most strongly that the perfect restoration of vision in 
many of these cases is a sufficient proof that the blood is 
situated in front of, and not in or behind, the retinal 
layers. He adduces other clinical evidence supporting 
this view. He apologises that in previously alluding to 
' one of the three cases he here reports, he had spoken of 
the lesion as a retinal hemorrhage, and now adds a note 
to explain that he so called it on account of its source 
having evidently been a retinal bloodvessel; he has no 
post-mortem evidence, but is quite satisfied that the blood 
is situated between the retina and vitreous body. 

Adams Frost, in his recently published work, The 
Fundus Oculi, describes the condition as a subhyaloid 
hemorrhage, and argues for its situation between the 



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A CASE OF SUDHYALOlD HEMORRHAGE, zvo 

retina and hyaloid membrane on clinical and ophthalmo- 
scopically observed facts, as follows : — 

(a) Patients often complain of seeing objects as through 
a red veil, which inclines him to think that the blood must 
be at any rate anterior to the rod and cone layer of the 
retina. 

(b) He considers that while retaining its red colour, 
the blood would equally obscure the retinal vessels in the 
ophthalmoscopic picture, whether placed in front or 
behind them. He does not therefore attach great import- 
ance in settling the position of these extravasations to 
Masselon's observation, recorded on p. 19, La Clinique 
Ophtalmologique, 1895, that in one case movements of the 
patient's head caused a variation in the upper horizontal 
edge of the blood which allowed retinal vessels at one 
time . obscured, at another to become visible. Adams 
Frost illustrates the ophthalmoscopic appearance of a case 
nearly four weeks old, in which retinal vessels are distinctly 
seen, whether in front or behind the red blood ; in the 
picture of this case, at an earlier stage, these vessels are 
not visible. He quotes, however, and it seems good evi- 
dence, Stanford Morton's case, recorded in the Ophthal- 
mological Society's Transactions, vol. ix, p. 145 ; in this 
case, when the blood became decolorised it still obscured 
the retinal vessels, a fact which almost compels one to 
admit that they must have been behind it ; a white exuda- 
tion behind them could only make them more con- 
spicuous. 

(c) Adams Frost endeavours to controvert Silcock's view 
that in his case (vide Transactions of the Ophthalmological 
Society, vol. vii, p. 176), where the straight edge of the 
hemorrhage was directed obliquely downwards, the blood 
was in the choroid, by saying that the shape and outline 
of the extravasation are against it being contained in the 
interstices of such a tissue as that of which the choroid 
coat consists. Masselon's hypha3ma-like, or hypopy on- 
like phenomenon of constant level could surely, in the 

u 2 






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294 A CASE OF SUJ3HYALOJD HEMORRHAGE. 

writer's opinion, not have been exhibited by blood con- 
tained in the interstices of such tissues as the retina or 
choroid. Silcock was supporting the view accepted when 
these cases were first clinically observed; he, however, 
recognises the possibility of a hemorrhage behind the 
retinal vessels obscuring them, as he figures his case with 
distended tortuous veins, of which the superior macular 
vein is partly concealed by the blood poured out. 

The observation that in some of these cases the refrac- 
tion at the surface of the extravasation is hypermetropic, 
usually about 2 D, must be so difficult to make on an 
uniform surface as to be of little weight, and even if 
accepted it hardly enables us to discriminate between 
blood in front of, or in the layers of, the retina, though it 
does not at first sight seem so likely that a hemorrhage 
in the choroid would give rise to such a local prominence. 
Lang, in the Ophthalmological Society's Transactions, 
vol. viii, p. 155, argues for the subhyaloid position, on 
account of the complete obscuration of retinal vessels 
at the edge of the extravasation, the red blurring of 
objects, as seen by the patients, and the common existence 
of a scotoma; he quotes De Wecker's authority for stating 
that a hemorrhage, if choroidal, will cause no such 
scotoma. As to the central situation, he accepts as a suffi- 
cient explanation the presence of a potential cavity, as 
stated by Marcus Gunn to exist in the macular region, 
owing to the more feeble attachment of the hyaloid mem- 
brane to the retina here than over the remainder of the 
fundus oculi. Haab, of Zurich, in Beitrage zur Augen- 
heilkunde, heft v, 1892, speaks of these cases as hemor- 
rhage between the retina and vitreous body, and refers to 
the%vritings of Leber, in Graefe and Saemisch's Hand- 
buch, band v, 553, who took a similar view; Haab relates 
six cases, all from a clinical point of view. 

Holmes Spicer, in the Royal London Ophthalmic Hos- 
pital Reports, vol. xiii, in a valuable monograph on this 
subject, mentions the differences of opinion as to the seat 



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A CASE OF SUBHYALOID HAEMORRHAGE. 295 

of the lesion. He points out how originally these hemor- 
rhages were considered to be derived from arteries. He 
differs from this opinion, and considers them to be venous 
in origin, on account of their spontaneous arrest; the 
turgiclity of the veins often noticed leads him in the same 
direction, and he regards the extravasations as too large 
to be capillary. He refers to the tendency to spontaneous 
haemorrhages elsewhere in the body. The opinion that 
the blood is derived from veins is now, I believe, generally 
accepted. 

Qther cases I have referred to for the purposes of this 
paper do not bear on the anatomical site of the lesion, but 
deal chiefly with predisposing causes. Eales, in the Bir- 
mingham Medical Review for July, 188.0, p. 262, has 
recorded four cases, and considers subhyaloid haemorrhage 
to be more common in males, attributing the comparative 
immunity of the opposite sex to the relief afforded by the 
function of menstruation. Spencer Watson, in the Trans- 
actions of the Ophthalmological Society, vol. i, p. 41, is 
impressed by the mystery of the reproductive functions in 
relating a case of subhyaloid hemorrhage occurring in a 
woman at the climacteric. In one of Hotz's cases referred 
to above, the occurrence of the sudden suppression of the 
menses certainly coincided with the onset of the eye 
trouble. 

Power narrated a case in a young woman, set. 29, in 
her sixth month of pregnancy, vide Bowman Lecture, in 
vol. viii of the Transactions of the Ophthalmological 
Society; the haemorrhage was immediately caused by a 
violent attack of retching, dependent, no doubt, upon 
the pregnancy. 

Hutchinson first drew attention to gout and constipa- 
tion as predisposing causes; Lang's case is one in point 
as regards the latter factor, and Stanford Morton's first 
case in vol. iv of the Transactions of the Ophthalmological 
Society illustrates well the former. Any straining effort 
may be the immediate exciting: cause. 



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296 A CASE OF SUBHYALOID HEMORRHAGE. 

Among others, R. W. M. Payne, De Schweinitz, 
A. Siegrist, Dimmer, &c, liave written on this subject, but 
no one records having obtained a specimen of the con- 
dition ; the only reference I have obtained to one having 
been seen post mortem is a statement of Dr. Anderson's 
reported in the Ophthalmological Review, 1888 ; in dis- 
cussing Mr. Lang's paper, Dr. Anderson announced merely 
that he had seen this condition of subhyaloid haemor- 
rhage post mortem, but no account was given. 

The above brief outline shows sufficiently that differ- 
ence of opinion as to the pathology and seat of so-called 
subhyaloid hemorrhage exists, and considering that every 
case carefully recorded may help to resolve our doubts, I 
venture to relate the following : — 

I. B., F., fet. 60, first came under Mr. Lawford's care as 
an out-patient of St. Thomas's Hospital on April 30, 1895. 
She complained of dimness of the sight of the right eye 
for 10 weeks and " multiple images" ; she stated that the 
sight had failed suddenly when at laundry work. Her 
history was that she had had severe attacks of nose 
bleeding on March 12 and 13, but it had been arrested in 
the out-patient department of St. Thomas's Hospital ; it 
recurred, however, on March 14, and was so severe as to 
require her admission, and she remained an in-patient of 
Dr. Orel's until March 26 ; the following facts are taken 
from the notes made while she was under Dr. Ord's care. 
" She had never had nose bleeding before, and had 
always had good health, except for an attack of what 
may have been influenza a fortnight before her admission. 
Her father had died of consumption, and her mother at 
the age of 65 in a fit." It is interesting in the latter con- 
nection to note that Gowers, in his Medical Ophthal- 
moscopy, legards the position of subhyaloid extravasation 
to be between retina and vitreous, and on p. 13 refers to 
the inheritance of the tendency to cerebral hemorrhage 
and its association -with retinal hemorrhage, and also 



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A CASE OF SUBHYALOID HAEMORRHAGE. 297 

speaks of the transmission of types of vascular arrange- 
ment as evidenced in the retinal vessels of parents and 
their children. I. B. had had a family of 10 children, of 
whom' Nos. 3, 4, 5, and 7 died very young, and one 
daughter died at the age of 18 of " consumption." The 
patient had had no miscarriages. 

The note of the heart is that its apex beat was 
1\ inches outside the nipple line ; the upper and inner 
limits of the cardiac dulness were normal. A soft systolic 
murmur was audible at the apex, and was conducted to 
the anterior axillary border; it was not audible at the 
base. The second cardiac sound was accentuated, and 
at the right base reduplicated. The pulse was 72 and 
somewhat tense. 

Urine. — Sp. gr. 1012 ; acid ; a heavy trace of albumin. 
She did not complain of her eyes, but the house physician 
examined them as a matter of routine in a renal case, but 
detected nothing abnormal. Her complaint of failure of 
sight in the right eye dated from before her admission 
uiixLcr Dr. Ord's care when she came to Mr. Lawford in the 
eye department, and it seems likely that the condition was 
overlooked by the house physician. She stated, however, 
that the sight had got worse since she left the ward on 
March 26. 

On April 30, 1895, Mr. Lawford recorded : 
E. V., sees hand dimly, but cannot count fingers. 
Pupil slightly greater than left ; acts to light. 

L. +5.D = 6/9 partly; + 9.D = 1 J. at 10^ inches. 
Ophthalmoscopic Examination. — Rigid Eye. — In the 
macular region is a large, roughly semicircular subhya- 
loid haemorrhage ; its upper border on a level with the 
centre of the OJ). is horizontal, sharply defined, and 
grey ; its lower border is less regular, and in part has a 
fringed appearance; the retinal vessels, in relation with 
the extravasation, are completely obscured. Below the 
main patch and in connection with the inferior macular 



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298 A CxVSS OF SUBHYALOID HZEMORRI-LVGS. 

vein is another patch of extravasatecl blood, less sharply 
defined, and much smaller than the central one ; fundus 
in other parte is apparently healthy. 

A week later there was no alteration in the vision of 
the affected eye, and an examination of the urine detected 
no albumin or sugar. 

On May 14, a fortnight after her first attendance, she 
could count fingers with the right eye at about 2 feet ; at 
this visit an additional ring of blood was noted at the 
yellow spot in relation with the first patch. 

On May 28 she thought the sight less black, and could 
count fingers at 3 feet in the lower part of the right field. 
The ophthalmoscopic note was: "The upper edge of the 
haemorrhage is very straight and sharp, and above it is a 
broad, whitish band also with a sharp border. The extra- 
vasation looks generally less dense than at her first visit a 
month ago. At the macula is an irregular haemorrhage, 
annular in form, which appears deeper than the larger 
haemorrhage. The separate haemorrhage at the lower 
part of the fundus has altered but little." The patient 
had had no more epistaxis, but last week some uterine 
haemorrhage, with pain, lasted two or three clays. At the 
close of the ophthalmoscopic examination she was told 
she might go, and tried to rise from her chair; she would 
have fallen had she not been caught, She seemed first to 
become paralysed on the right side of the body ; soon the 
left thumb began twitching, and this movement spread to 
the hand, arm, face, and leg, and then became general on 
both sides of the body. She was at once admitted to a 
medical ward under Dr. Sharkey's care. She remained in 
an unconscious condition, but at first could be aroused by 
a pin prick, but not sufficiently to answer questions. The 
condition of the heart and pulse was recorded in terms 
which agree with the description when she was under Dr. 
Ord, six weeks before. The urine was passed involun- 
tarily; its sp.gr. was 1020; reaction, acid; contained a 
rather large trace of albumin, but no sugar. 



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A CASE OF SUBHYALOID HAEMORRHAGE. 299 

The condition remained the same, except that the 
right cheek became paralysed and the breathing ster- 
torous, while the coma deepened and the temperature 
gradually rose to 105*2° F., and shortly before her death, 
on May 31, to 106*4° F. On June 1 the autopsy was 
made. 

The heart weighed 12^- ozs., the left ventricle was 
hypertrophied, and the right dilated. There was atheroma 
of the aorta, extending through the aortic valve to both 
sides of the adjacent mitral flap. 

The kidneys were small, and showed all the appearances 
of chronic interstitial nephritis, with a few cysts. 

Brain. — The cortical veins were much distended, and 
there was a little blood-stained fluid at the base. The 
basal cerebral arteries were the subject of much athero- 
matous change. In the left internal capsule was a hemor- 
rhage of considerable size, which had ruptured into the 
lateral and third ventricles. The fourth ventricle con- 
tained a little blood-stained fluid ; the left motor tract in 
the hemisphere was infiltrated with blood. 

Uterus. — The endometrium was blood-stained. 

The right eye was excised for examination later. It 
was hardened in a 10 per cent, solution of formol for 
four weeks, then frozen and divided equatorially. The 
haemorrhage showed plainly to the naked eye as a reddish- 
brown patch in the central region; its upper edge was 
fairly horizontal, its lower edge semi-circular but irregular ; 
the other haemorrhage, noticed ophthalmoscopically below 
the macular region, was not evident. The retina appeared 
a good deal folded, and one fold seemed to have pro- 
truded through the patch of haemorrhage. The posterior 
half of the globe was then imbedded in celloidin and 
sections cut. A large number were prepared by the 
method of double staining with hematoxylin and eosiu. 



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302 A CASE OF SUBHYALOID HEMORRHAGE. 

The section here drawn under two different degrees of 
magnification was chosen for reproduction as it perhaps 
best indicates the points for which this paper is written, 
viz., to assist in settling the vexed question of the exact 
site of the blood extravasated in so-called subhyaloid 
haemorrhage ; all the sections concur as to this point, but 
not all are so distinct in showing the double membrane 
which will be noticed in the drawing running for the most 
part over the surface of the blood. The membrane nearest 
the blood shows very clearly in places that there are 
nucleated cells in connection with it, while the other 
membrane is structureless in character. The first of these 
is evidently the internal or anterior limiting membrane of 
the retina, while the second, there can be equally no 
doubt, is the hyaloid membrane of the vitreous body. 
For the most part, the two membranes will be noticed to 
run practically parallel, with a very slight interval between 
them, and both are on the surface of the extravasated 
bjloocl ; at one point, however, a quite small number of 
blood corpuscles is seen in the specimen between the two 
/membranes, which are here, for a short distance, dissoci- 
ated; here the blood has apparently burst through the 
internal limiting membrane of the retina, but has been 
checked in its attempted passage into the vitreous by the 
hyaloid membrane. The structure of the retina definitely 
shows the section to have been made near the macular 
region; at the end of the section furthest from the optic 
papilla the blood has succeeded <m bursting through both 
membranes in considerable quantity, and has spread itself 
out for some distance as a thin layer on the surface of the 
hyaloid membrane. It will alsd) be noticed that the layers 
of the retina are not in themselves infiltrated ; the blood 
has found less resistance in farcing up the anterior limit- 
ing membrane than in invading the layers of the retina, 
and in one place the pressure pas caused the blood to pass 
through both membranes wijthout any of it forcing its 
way in the opposite direction into the retinal structures, 



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A CASE OF SUBHYALO.ID HEMORRHAGE. 303 

The sections give no cine as to which of the retinal vessels 
was the source of the haemorrhage. In the blood can be 
seen large numbers of multinucleated cells, presumably 
macrophages in process of effecting the absorption of an 
extravasation of many weeks' duration. In speaking of 
the specimen, the word " clot" has been advisedly avoided, 
as we have no means of saying in what condition the 
blood exists, and Masselon's case certainly suggests that, 
for a time, at least, it retains its fluid properties. The 
change of colour which these haemorrhages are seen to 
undergo, when watched ophthalmoscopically over some 
period, points in the same direction ; the upper part 
becomes lighter in tint, and the lower deeper, apparently 
from sinking of the red corpuscles. 

The drawings sufficiently explain themselves, and the 
sections are the best of evidence that subhyaloid haemor- 
rhage should be classed, as most writers have classed the 
disease, under the head of retinal haemorrhages ; the 
disease is so well defined clinically and ophthalmoscopic- 
ally that there can be little chance of error in assuming 
this example, which was, during life, in all respects 
typical, as a correct indication of the site of the lesion in 
most, if not all, of these cases. 

The blood is then apparently poured out from a retinal 
vessel, does not invade the retinal layers', but detaches 
the internal limiting membrane from their surface and 
accumulates in the space so formed; it may, however, 
undoubtedly break through not only the internal limiting 
membrane but also the hyaloid membrane, and pass into 
the vitreous. Though the specimen proves nothing in 
this direction, it seems probable that to tear off the 
internal limiting membrane from the retina would require 
blood at a moderate pressure from a minute artery, and 
that blood from a vein would be insufficient to effect this 
separation ; in the situation in which the blood is seen, 
spontaneous arrest of haemorrhage from a small arteriole 
might quite well be expected. The possibility of estimating 



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304 A CASE OF SUB HYALOID HiEMORUHAGE. 

the surface of the hemorrhage during life to be hyper- 
metropic seems doubtful; at its thickest part the layer 
of blood is not thicker than the retina upon which it lies. 



REFERENCES NOT GIVEN IN THE TEXT. 

Hartridge. Trans. Ophth. Soc, vol. xi. 

Unterharnscheidt. Inaugl. Dissert. Bonn, 1877 ; " Uber die Apoplexie 
zw. Retina und Vitreous." 

Mellinger. Klin. Monatsblatter, 1888, p. 404. 

De Schweinitz. Amer. Journal of Ophthalmology, St. Louis, 1896, 
vol. xiii, p. 45. 

A. Siegrist. Mittheil. a. Klin, unci Med. Instit. der Schweiz, Basel and 
Leipzig, 1895. 

Dimmer. Beitrage z. Augenheilk, 1894, heft xv, p. 73. 

R. W. M. Payne. Occidental Med. Times, Sacramento, vol. x, p. 21, 
1896. 



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305 



THE DEVELOPMENT OF THE POSTERIOR ELASTIC LAMINA 
OF THE CORNEA OR MEMBRANE OF DESCEMET. 

By E. Treacher Collins, Assistant Surgeon to the Hospital. 

The development of the cornea in the chick has been 
described as follows* :— " The substantia propria corneae 
first appears in the chick as a thin homogeneous layer 
lying immediately within this epithelium (the surface 
epithelium). Into this homogeneous layer mesoblastic 
cells pass from the margin, greatly thickening it, and 
producing eventually the regular layers of fibrous tissue 
which are characteristic of the cornea. No cells pass into 
the most anterior or into the most posterior stratum, 
which remain homogeneous (anterior and posterior homo- 
geneous lamellae of Bowman). The epithelium of the 
posterior homogeneous lamella or membrane of Descemet 
is derived from mesoblast cells, which grow in like the 
corneal corpuscles from the margin, and spread themselves 
over the posterior surface of the cornea, thus separating 
this from the iris and anterior surface of the lens/' 

With regard to the origin of the homogeneous layer 
which first separates the lens vesicle from the surface 
epithelium in the chick, and which remains ultimately as 
the anterior and posterior elastic laminae, two different 
views have been put forward. Kessler regards it as a 
secretion of the epidermis, and Kolliker as of mesoblastic 
origin. 

In mammals, this homogeneous layer has not been met 
with.f Hertwig says: — "As soon as the lens vesicle in 
mammals is fully constricted off, it is already enveloped 
by a thin sheet of mesenchyma with few cells, which 
separates it from the epidermis. The thin layer is rapidly 

* Quain's Anatomy, lOfch edition^ voi. i, Pfc. 1, p. 87. 

f Text-Book of Embryology, Translation of 3rd Grerman Edition, p. 477. 



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306 THE DEVELOPMENT OF THE 

thickened by the immigration of cells from the vicinity. 
Then it is separated into two layers^ the pupillary mem- 
brane and the fundament of the cornea." 

He makes no mention as to the mode of origin of the 
anterior and posterior elastic laminse in mammals. 

In foetal mice which I have examined, I find at one 
stage the surface epithelium separated from the lens by a 
collection of round cells, but no vestige amongst them, 
whatever, of a hyaline membrane. 

The youngest human foetal eye of which I have 
sections is one in which the lids have just commenced to 
sprout out, but where they have not yet met in front of the 
globe. I have no statement as to the supposed age of the 
foetus from which this specimen was taken, but I have 
another in which the lids have met in front of the globe 
which was stated to be from a foetus of the tenth week, 
so, presumably, it is from a foetus younger than that. 

The cornea in these specimens is seen to consist, from 
before backwards, of the following layers. Epithelial cells 
in places appearing two rows thick; immediately in contact 
with them, and not separated by any homogeneous mem- 
brane, layers of cells with elongated nuclei and fibres. 
The nuclei of these cells are very much closer together than 
those of the corneal corpuscles in the adult cornea, the 
amount of fibrous tissue between them being very much 
less. Behind this laminated fibrous and cellular tissue is 
seen an extremely thin hyaline layer, posterior to which 
are closely packed cells with round nuclei, showing a 
tendency to arrangement into two layers, the anterior 
evidently being the lining endothelium of Descemet's 
membrane, and the posterior the commencement of the 
antero-fibrovascular sheath of the lens. I am unable to 
find any blood vessels amongst the round cells, though 
there are many already formed at the posterior part of 
the lens. 

In a specimen I have of a human foetal eye of the 
fourth month, blood vessels are distinctly seen in the 



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POSTERIOR ELASTIC LAMINA OF THE CORNEA. 307 

antero-fibrovascular sheath. The posterior elastic lamina 
is still only seen as an exceedingly delicate line, and 
nothing of a homogeneous layer is yet visible between 
the anterior epithelium and substantia propria of the 
cornea. 

In a human foetal eye, said to be of the sixth month, 
Bowman's membrane, the anterior elastic lamina, is very 
distinctly seen, and the posterior elastic lamina is con- 
siderably wider than it was at the fourth month. 

It is evident, then, from this, that in mammals there is 
a stage in the development of the cornea where no elastic 
membrane is present. In man, when a very delicate 
rudiment of the posterior elastic lamina is just discernible, 
it is already lined by endothelial cells, and from this time 
onward it gradually increases in thickness. The question 
then suggests itself: Is the posterior elastic lamina a 
product of the endothelial cells lining it? 

I have, in former writings,"* attempted to show that 
the two other hyaline membranes in the eye, viz., the 
capsule of the lens and the membrane of Bruch, are the 
product of epithelial cells lining them, mainly on patho- 
logical grounds. Can Descemet's membrane, in the same 
way, be shown to be the product of the cells lining it? 

I may, in the first place, point out this difference : the 
cells lining the lens capsule are the product of cuticular 
epiblast, those lining the membrane of Bruch are derived 
from neural epiblast, whilst those lining Descemet's mem- 
brane are generally believed to be mesoblastic in origin. 

Otto Schirmerf showed that after wounds of the lens 
capsule the gap first became closed by cells derived from 
those lining the capsule, and that afterwards a new 
hyaline layer made its appearance, presumably the pro- 
duct of these cells. 

When Descemet's membrane is wounded and its ends 

* Trans. Ophth. Soc, vol. xii, p. 89. "Researches into tbe Anatomy 
and Pathology of the Eye," p. 13-18, and 88-91. 
f Arehiv f . Ophth., Bd. xxxv, ab. 1, s. 220. 
VOL. XIV. 



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308 THE DEVELOPMENT OF THE 

have become retracted, does a new hyaline layer form in 
the gap left ? Or, if the endothelial cells become detached, 
do they ever develop a new hyaline layer in front of 
them ? 

B. Gepner, jun., described, in 1890,* the case of a man, 
aet. 21, who had an iridectomy performed several years 
previously for iritis. The eye was removed on account 
of inflammation following a blow. A. gap was found in 
Descemet's membrane in the region of the cicatrix, which 
was bridged across by a layer of hyaline membrane of the 
same structure as Descemet's membrane, and lined by 
endothelial cells. 

Wagenmann, in 1891,f recorded the case of a patient, 
set. 57, who, two and a half years previously, had had a 
cataract extracted from his eye by the modified linear 
operation of v. Graefe, and who, while in the hospital for 
operation on his other eye, died of pneumonia. The eye 
first operated on was removed shortly after death, and, on 
.microscopical examination of the seat of the wound, the 
' two cut extremities of Descemet's membrane could be seen, 
separated by a slightly protuberant film of tissue, posterior 
to which was a layer of newly formed hyaline substance 
lined by endothelial cells. Wagenmann has no doubt 
that the hyaline layer was derived from the endothelium. 

Alt mentions a casef in which there was a considerable 
new formation of fibrous tissue on the inner surface of 
Descemet's membrane, which was covered on the surface 
towards the anterior chamber by a newly-formed second- 
ary membrane of Descemet, lined by endothelium, and he 
says : — " I think that this case shows that Descemet's 
endothelium can not only form lamellated connective 
tissue, similar to that of the corneal tissue, but that it can 
form, and, perhaps, originally forms, the vitreous mem- 
brane, which we call that of Descemet." 

# Archiv £. Oplith., Bd. xxxvi, ab. 4, s. 255. 
f Archiv f. Oplith., Bd. xxxvii, ab. 3, s. 21. 
$ Amer. Journal of Oplith., vol. xiii. 



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POSTERIOR ELASTIC LAMINA OF THE CORNEA. 309 

I have examined a large number of specimens of eyes 
with corneal cicatrices, resulting from wounds, in order to 
see if I could find any in which there had been a new 
formation of a hyaline membrane similar to the posterior 
elastic lamina. I have only discovered two, and I must 
conclude that such a new formation is by no means a 
common occurrence. 

My first case is that of a man set. 46, who, 26 years 
previously, had received an injury to his right eye from 
a piece of steel; it had been quite blind 15 years; lately 
had become painful, and consequently was excised. 

The surface of the cornea appeared rough, and there 
was in its lower part a faint scar. The anterior chamber 
was deep, and in the lower part of the iris, opposite the 
scar in the cornea, was a small hole. The lens was absent, 
and the vitreous, fluid; attached by a thin tag of grey 
membrane to the posterior border of the ciliary body was 
a small fragment of metal 2 mm. square. 

On microscopical examination of sections of the cornea, 
the line of cicatrix can be seen passing through it some- 
what obliquely. There is a gap in Bowman's membrane 
filled with fibrous tissue ; the laminse of the cornea are 
somewhat irregularly disposed, and there is a slight excess 
of cells. On the posterior surface, in the region of the 
cicatrix, the two divided ends of the posterior elastic 
lamina are seen turned somewhat forwards and separated 
from one another by fibrous tissue, while bridging over 
the gap posteriorly is a thin hyaline layer, which can be 
traced on each side of the wound for a short distance as 
a distinct layer in contact with the posterior elastic lamina, 
with which, a little further out still, it becomes blended. 

The endothelium from the posterior surface of Desce- 
met's membrane, has, in the preparation of the specimen, 
become somewhat displaced, but it can be seen to form a 
continuous single row of cells all over the posterior sur- 
face of the cicatrix continuous with the single layer else- 
where. 

x 2 



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The second case is one of which I have already pul 
lished a good many details in these Reports.* 

The patient was a man e&t. 44, who came to the hog 
pital with absolute glaucoma in his right eye, and sufferin 
great pain. An iridectomy was performed. Five month 
later, the pain still continuing and the patient refusing t 
have the eye excised, an optico-ciliary neurotomy wa 
done. Two years after this, and 2^ years after th 
iridectomy, the pain returned, and the patient then cor 
sented to have his eye enucleated. 




Figure showing new-formed hyaline membrane on posterior surface < 

cicatricial tissue in Case 2. 



Microscopical examination of the cornea in the regio 
of the operation, shows a broad band of cicatricial tissu 
with small blood vessels coursing through it. Th 
divided ends of Descemet's membrane are found widel 
separated, the more peripheral end is curved a little back 
wards. Between the two ends there projects backward 
some new-formed fibrous tissue, which, at one part, i 
dense and laminated, resembling closely normal corner 
tissue. Some of this new-formed fibrous tissue extenc 
for a short distance inwards toward the centre of th 
cornea behind the posterior elastic lamina. 

On the posterior surface of the dense new-forme 

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* Vol. xiii, p. 200. 



POSTERIOR ELASTIC LAMINA OF THE CORNEA. 311 

laminated fibrous tissue is seen a thin hyaline membrane 
of the same structure as the posterior elastic lamina, to 
which, on the inner side, it becomes united at an acute 
angle. It is evident that in the recent state this thin 
layer of hyaline membrane was lined by a single layer of 
endothelial cells continuous with those lining the posterior 
elastic lamina. In the specimen, the endothelium has 
become displaced backwards from, the hyaline membrane. 

On the inner surface of Descemet's membrane are 
sometimes seen little hyaline nodules, indistinguishable in 
structure from that membrane; they may be compared 
with the hyaline nodules so frequently met with on the 
inner surface of the membrane of Bruch, which, however, 
are usually much larger. 

These latter nodules are apparently the product of the 
pigment epithelial cells of the retina, and the following 
reasons tend to show that the nodules which form on the 
inner surface of Descemet's membrane are formed by its 
lining endothelium. First, it is -unlikely that an inert base- 
ment membrane should give rise to outgrowths ; it is 
much more probable the active endothelial cells should 
undergo some change which would result in the produo 
tion of these hyaline masses. Secondly, these nodules are 
only met with on the surface of the membrane where the 
cells are situated. If they were thickenings of the mem- 
brane itself we should expect to meet with them on both 
surfaces. 

If, then, it may be assumed that under some abnormal 
stimulus the endothelial cells lining the posterior elastic 
lamina are capable of producing nodules, or a layer of a 
substance indistinguishable in structure from the elastic 
lamina, it seems fair to assume that the elastic lamina 
itself is originally developed from them. 



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312 



OX MENINGITIS FOLLOWING- EXCISION OP THE EYEBALL 
FOR PANOPHTHALMITIS. 

By C. Devereux Marshall, Curator. 

Case I. — George G., set. 21, was admitted on November 24, 
1886, for the treatment of thickened capsule following a trau- 
matic cataract which was caused by an accident with a gun cap 
seven years previously. 

The following day (November 25) the capsule was needled 
and was found to be very tough. On November 29 an incision 
was made, and the caps ale removed with forceps. On Decem- 
ber 1 the iris was discoloured, the pupil not dilated, and there 
was considerable pain. December 2, hypopyon present. Pupil 
filled with yellowish lymph. This state of things continued 
until December 6, when the eye was excised. The conjunctival 
sac was washed out, both before and after the operation, with 
sol. hyd. perchloride 1 : 3500. During the excision the globe 
w r as wounded, and the purulent material escaped into the 
socket. On December 7 the temperature was 103°. Patient 
complained of great pain in the head. The orbit was syringed 
out with perchloride lotion, and a drainage tube inserted 
between the lids, an ice bag was applied to the head, and a 
mercurial purge administered. Urine sp. gr, 1030. No albu- 
min. No sugar. Later in the day the head was shaved, and 
ung. hydrag. was rubbed in. 

On December 8 the patient was very restless, He com- 
plained of much pain in the back of the head, but sleep was 
obtained by means of morphine. The neck was bent back- 
wards, and was very stiff. There was hardly any discharge 
from the orbit. Pie died the same evening, having previously 
developed well marked Cheyne-Stokes respiration. 

The following is the pathological description of the eye : — 

The globe is collapsed, a large piece has been cut out of the 
sclerotic during removal, and a second hole made in another 
part. The eyeball contains pus. There is no scar in the cornea, 
but a ring of suppuration in it. The retina is indistinguishable 



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On MENINGITIS, ETC. 



313 



and the choroid is in a state of suppurative inflammation. The 
anterior chamber is occupied by a layer of purolymph, adherent 
both to the cornea and iris. The purulent mass in the vitreous 
is very adherent to the iris. There is marked episcleral inflam- 
mation, and the orbital fat is adherent to the sclera, which is 
©edematous and thick. 

Post-mortem examination made 12 hours after death. 

There is some oedema of the scalp, and strong adhesions 
between the membranes and skull-cap ; the former are greatly 
congested. The sinuses are all full of dark blood which is par- 
tially coagulated. When removing the brain a large quantity of 
yellowish, semi-opaque cerebro-spinal fluid escaped. The surface 
of the brain is very vascular. There is lymph in all the snlci on 
the convexity of the brain, and as much on one side as on 
the other; the anterior parts of the hemispheres are glued 
together. 

At the base of the brain the lymph is much less diffusely 
distributed. In the interpeduncular space there is a distinct 
layer which extends over the pons, medulla oblongata, and 
cerebellum. The hemispheres are glued together inferiorly in 
front of the chiasma. The ventricles contain much turbid 
fluid. There are no tubercles. The lymph everywhere looks 
fresh, and there is nothing suggestive of previous meningitis. 

Case II. — Robert C, ast. 72, was admitted on August 30, 
1889, with a history that some "hay-seed" flew into the 
right eye five to six weeks ago. The eye was injected, 
and there was some discharge from the conjunctiva. The 
cornea was perforated, and there was a large prolapse of the 
iris. 

He was anaesthetised as soon as possible, and the bulging 
iris was cut across and freed from the cornea and a large 
portion removed. A small piece of conjunctiva was turned 
into the corneal wound and a dry compress applied. 

September 1. Some discharge and hyphaema. 

September 2. The lens escaped and was found beneath 
dressing. The vitreous is bulging. 

On September 5, as the eye was suppurating, an anaesthetic 
was given, and it was excised, the socket being washed with 
lotion hydrag. perchlor. 1 : 3500. 



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314 ON MENINGITIS FOLLOWING. EXCISION 

When removed there was a central perforation of the 
cornea with a mass protruding through it. On section, some 
fluid vitreous escaped, the anterior portion of it was suppu- 
rating, and there were numerous recent hemorrhages in the 
retina. 

On September 6 the patient showed no bad symptoms until 
1 p.m., being about 24 hours after the operation ; he then vomited, 
felt cold, and shivered. He was at once put to bed, with hot- 
water bottles, and brandy was given. 

2,30 p.m. Patient unconscious. Temperature 103°. Picking 
at bedclothes. Breathing stertorous, 40 to the minute. Pulse 
88, thready. No sign of paresis. Three leeches and ice cap 
applied to the head. 

September 7. Rigidity, especially of the left arm. Slight 
opisthotonos. Patient died at 7 a.m., being about 42 hours 
after the excision. 

Post-mortem examination made 26 hours after death. 

There is considerable adhesion between the membrane and 
the calvaria, but not much injection of the former. 

There is lymph covering the sulci on the convexity of the 
brain, and some adhesions (probably old) exist between the 
membranes on the two sides of the longitudinal fissure and also 
about the fissure of Sylvius. 

There is no marked engorgement of the venous sinuses, 
nor any changes about the optic nerve at its entrance into the 
orbit, there is no lymph at the base of the brain, and the optic 
nerves are, apparently, quite healthy. 

Case III,— Lucy A., aet. 46, was admitted on November 17, 
1894, with the following history :— On the morning of this 
day, while mending a boot, the awl which she was using flew 
out of her hand and wounded the right eye. 

Her vision had never been very good, and the right eye was 
not so good as the left, the sight having been weak since an 
attack of measles in childhood. 

On admission, a wound was seen running along the lower 
part of the cornea which was collapsed. There was no A.C. 
A coloboma of the iris extended downwards, but no iris was 
enoangied in the wound. Some shreddy matter (lens or 
vitreous) was hanging from the wound, and there was some 



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OF THE EYEBALL FOR PANOPHTHALMITIS, 315 

blood in the pupil, Y = hand- movement. The cornea of the 

other eye was nebulous, Y = — . 

J 60 

The wound was cleansed, and all shreddy matter was removed. 
The eye did not do well, and, two days later, there was pano- 
phthalmitis. Patient absolutely refused to have anything 
done, and leffc the hospital, on her own responsibility and 
against advice, on November 21. 

She did not attend again until December 8, 1894, when she 
was at once admitted. She was very collapsed and in great 
pain ; this latter symptom had continued ever since she had 
left the hospital. 

Ether was given, and the eye was at once excised. The 
tissues were very much matted together, the globe was more or 
less collapsed, and contained pus, which escaped during the 
operation, the capsule of Tenon could not be made out, and some 
orbital fat remained attached to the globe. The socket was 
irrigated with perchloride of mercury lotion 1 : 4000. 

At 1 o'clock P.M. on December 9 the temperature was 103°. 
There was considerable swelling of the lids and conjunctiva. 
She complained of severe pain in the head, and was much 
collapsed. 

At 4 p.m. the temperature was 104°, there was frequent 
retching, some twitching of the hands, and patient was very 
restless. 

December 10. Bowels freely opened by means of castor-oil. 
Temperature 102°. A deep incision made through the outer 
canthus in order to drain the socket. The temperature then fell 
to 100°. Later in the day the patient became very restless, and 
complained of much pain in head and neck. Temperature 104 4°. 
Cheyue-Stokes inspiration. A cold pack was ordered which 
caused the temperature to fall to 103°. At 9.30 p.m. the cold 
pack was again applied, after which the temperature fell to 102°. 

Patient gradually became comatose, and died at midnight. 

Autopsy 15 hours after death. 

Higor mortis had partially passed off. 

On removing the calvaria the brain and the meninges were 
congested, and the membranes adherent to the surface of the 
brain. At the base there was a considerable quantity of pus 
which extended over that portion of the brain ^occupying the 



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316 ON MENINGITIS FOLLOWING EXCISION 

middle and posterior fossae of the sknll. The inferior surfaces 
of the frontal lobes were also somewhat infiltrated with pus, 
bat not to such a great extent. 

Pus and lymph extended along the Sylvian fissures on to 
the surfaces of the parietal lobes on both sides. 

The cranial nerves were matted together by inflammatory 
exudation, and the vertebral and carotid arteries were sur- 
rounded with pus. The optic nerves, chiasma, and optic tracts 
were completely covered with lymph. 

On tracing the optic nerves forward, they were both found 
to be somewhat enlarged, but the orbital part of the right 
nerve was intensely swollen and of a dark blue colour, looking 
very like a distended vein. AH the surrounding fat was infil- 
trated w r ith pus. 

Microscopic Examination of the Optic Nerves. 

Right Nerve. — Far back, near the chiasma, there is much 
cell infiltration, especially round the periphery of the nerve and 
nerve sheath ; as this is traced towards the orbit the inflam- 
matory signs are seen to get more and more marked, blood 
and pus pervade every part, the nerve fibres are entirely 
destroyed. 

Left Nerve. — The signs of inflammation are confined to the 
nerve sheath ; this gets less as it is traced towards the orbit 
from the chiasma. Within the globe there is no neuritis, 
retinitis, choroiditis, nor swelling of the disc. 

Microscopic Examination of the Bight Eye. — Within the eye 
there is a quantity of pus, the retina is inflamed and swollen 
and enveloped in purulent exudation. There is intense optic 
neuritis and swelling of the disc, the nerve fibres can hardly 
be recognised, and the optic nerve sheath, the sclera and the 
adherent orbital tissues are barely distinguishable from one 
another. 

The thoracic and abdominal viscera were healthy. 

Case IV. — Nathaniel T., set. 60, was admitted on February 
13, 1895, with the following history. Bather more than a 
year ago, while pruning a hedge, a thorn struck the right eye, 
and he thinks it remained in. He was attended by his doctor, 
and the eye got quiet, though there was not much sight left. 



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OF THE EYEBALL FOR PANOPHTHALMITIS. 317 

He resumed his work for eight months without suffering any 
inconvenience from it. A month ago it again becamed inflamed 
without any obvious cause. 

State on admission: — There is only the sloughing remains 
of the right eye left. The cornea has ulcerated, and there is 
some shreddy lymph hanging from the centre, surrounded by 
chemosed -conjunctiva. No mucocele. The left eye is healthy. 
Temperature 93°. 

.February 14, 1895. The patient being under ether the eye 
was excised, the contents partially escaping. The socket was 
not irrigated, but the nerve was cut so close to the eyeball that 
another piece was picked up and cut off. 

On the following morning the socket looked healthy. Tem- 
perature 99°. 

5 p.m. Temperature 102°. Patient is restless, and resents 
examination. Complains of headache, and has vomited several 
times. Croton oil (m. ii) given. Ice bag applied to the head. 

9.30 p.m. Patient unconscious. Temperature 101°. Very 
restless. Pulse 70. Respiration 40. Socket looks quite 
healthy. 

February 16. Patient rather more quiet. No optic Neu- 
ritis. Temperature lOO^ . At 4 p.m., however, he was coma- 
tose, and could not be roused. There was right facial paralysis 
but no paralysis of limbs. Pulse 140°, weak and thready. 
Cheyne- Stokes respiration. Temperature 99'6°. Patient 
gradually got weaker, and died at 2.30 a.m., February 17, being 
about 58 hours after the excision. 

Autopsy 34 hours after death. 

The skull was opened in the usual way. 

The meninges are very adherent to the calvaria and much 
inflamed. On removing the dura mater the pus and lymph are 
seen to extend in all directions, but is most abundant along 
the vessels and in the sulci. It extends into the superior 
longitudinal fissure and on to the surface of the corpus 
callosum. The superior surface of the middle lobe of the 
cerebellum is also covered with the same material. At places 
beneath the pia mater there are collections of pus which, at 
one spot, forms a superficial abscess about the size of a six- 
penny piece. 

Both hemispheres are about equally affected. 



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318 ON MENINGITIS FOLLOWING EXCISION 

At the base of the brain there are some inflammatory adhe- 
sions, but the evidence of meningitis here is so slight that it 
might easily be overlooked. The optic nerves appear healthy, 
but there is a little matting together of tissues around the 
third nerve, and this is all that is apparent to the naked eye. 
The inferior surface of the cerebellum is healthy, but there is 
slight thickening of the pia mater and arachnoid covering the 
inferior surface of the frontal lobe — probably not recent. 
Microscopical examination of the orbital part of the right 
optic nerve shows no inflammatory changes, but some blood is 
extravasated into the sheath on account of the recent section 
which was made when the eye was excised. 

The left optic nerve is healthy, and shows no pathological 
change. The kidneys are both somewhat granular, and the 
kidney substance tears when removing the capsule. The left 
kidney contains some small cysts in the cortex. 

All the other abdominal and the thoracic viscera are healthy. 

Case V.— John J., get. 70, was admitted on March 17, 1896, 
in the following condition : — He had a complete cataract in the 
left, and a commencing cataract in the right eye. 

On January 11, 1896, a preliminary iridectomy was done on 
the left, and from this he recovered perfectly. He was now 
admitted for the extraction, the vision in that eye being P.L., 
with good projection and normal tension. 

The extraction was performed on March 18 in the usual 
manner and without any complications, the cortex, however, 
was rather sticky, and a small quantity could not be got away 
readily, so it was left, The following day there was a shallow, 
anterior chamber, but the wound was gaping slightly towards 
the inner angle. The eye did quite well for four days, but, on 
March 22, patient complained of pain. The A,C. had reformed 
and there was some opaque matter in it; there was great 
photophobia and lacrimation and considerable oedema of the 
conjunctiva. Atropine was applied three times a day, and hot 
boracic bathing* ordered. 

On March 25 there was a good deal of lymph in the anterior 
chamber. The wound was re-opened and the lymph withdrawn. 
Chlorine water was injected into the chamber, and some 
vitreous was lost. 



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OF THE EYEBALL FOR PANOPHTHALMITIS. 319 

On April 5 there was still lymph in the pupil. The 
wound was bulging" slightly and gaping in the middle. The 
tension was + , but there was very little pain. 

On April 11 the patient was put under ether, and the 
eye was excised. Whilst this was being done the globe rup- 
tured, and some of the purulent contents escaped. The con- 
junctival sac was irrigated before the operation, but there was 
no irrigation afterwards ; the wound was simply allowed to 
bleed freely for some minutes. 

On April 12 the temperature was 101-8°. Patient was 
quiet and free from paim During the day he became very 
restless, complained much of headache, and was aroused only 
with difficulty. There was some blood-clot in the conjunctival 
sac ; this was squeezed out, and the socket was irrigated with 
carbolic lotion, 1 : 40. Temperature at 3.0 p.m. was 103'2 o . 
He was then cold sponged, but without effect. At 5.30 p.m. 
the temperature had risen to 104'4°. He was again sponged . 
This reduced it, an hour afterwards, to 102'8°. 

Inj. morph. hypod. 3 m. ij, was given. This made patient 
more quiet, and, on the following morning at 2.0 a.m., the 
temperature was 98*4°. 

On April 13 the general condition of the patient was much 
the same. He was very irritable, and 3 as he had not voided 
any urine for some hours, a catheter was passed, and 15 oz. 
of ammoniacal urine was drawn off. The right optic disc was 
congested, but there was no optic neuritis and no retinal 
hasmorrhages. Calomel, gr. v, was given, and Ung. Hydrag; 
5 j was ordered for daily inunction. 

On April 14 the right optic disc was much congested. 
There was stiffness of the neck and pain on movement. Fifteen 
ounces of urine was again drawn off. Temperature subnormal. 

April 15. " The whole body is more or less twitching. The 
back appears to be very stiff, and the patient lies curled up on 
the right side." Still no optic neuritis, nor hemorrhages. 
Temperature 100°. Patient gradually sank, and died at 1.0 pj, 
this being 96 hours after the excision. 

The following is the description of the eye when removed :^ 

The globe is partially collapsed, and the extraction wound 
is open and gaping ♦ there is a large amount of lymph and some 
lens matter in the pupil. The lens is absent, and the whole 



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320 ON MENINGITIS FOLLOWING EXCISION 

globe is filled with thick, purulent material. The retina and 
choroid are in situ. 

Autopsy five hours after death. 

Rigor mortis is present in the lower extremities and 
shoulders. 

There is much echymosis of the right eyelids, and the same 
thing is seen on the left side ; there is a good deal of blood-clot 
in the orbit, and much staining of the orbital tissues. 

After having sawn through the calvaria in the usual manner 
the following condition was noted : The meninges are so adherent 
to the bone that considerable difficulty is experienced in sepa- 
rating the two without, at the same time, tearing them and the 
brain away from the base of the skull. The dura mater is very 
adherent to the surface of the brain, and there is extensive 
purulent inflammation, which is most marked along the sulci 
and blood-vessels. 

Along the superior longitudinal sinus there is a considerable 
amount of lymph deposited, and the membranes here are 
specially adherent. This extends along the falx cerebri to the 
corpus callosum. The upper surface of the cerebellum is covered 
with purulent material. 

At the base of the brain there is a good deal of purulent 
meningitis; this is most marked in the region of, the circle of 
Willis ; there is considerable thickening of the arachnoid and 
pia mater over the chiasma and in the immediate vicinity. 

The left optic nerve is a little swollen and slightly congested, 
that of the opposite side being healthy. There is inflammation 
of the meninges covering the under surface of the frontal lobes, 
but the lower surface of the temporo-sphenoidal lobes are hardly 
affected. The inferior surface of the cerebellum has a quantity 
of purulent material on it; so, also, has the pons and medulla 
oblongata. There is very marked atheroma of all the arteries 
and they stand widely open when cut. The whole brain is softer 

than natural. 

None of the sinuses contain any pus, nor are they throm- 
bosed, but there is some post-mortem clot in them. On the 
right'side there is a little pus near the Gasserian ganglion, but 
this is apparently outside the cavernous sinus. 

The tissues of the right orbit are quite healthy, and show 
no inflammatory changes. 



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OF THE EYEBALL FOR PANOPHTHALMITIS." 321 

The right kidney is healthy and not granular. 
The liver is rather smaller than natural. The ears are 
healthy, and neither membrane is perforated. 

The five cases here recorded bring forward a subject 
which has frequently been under discussion, and one 
which, cannot fail to be of great interest to the ophthalmic 
surgeon. They belong to a well recognised though, 
fortunately, rare class of case in which death from 
meningitis rapidly follows the enucleation of an eyeball 
which is in a state of suppuration. It is of the greatest 
importance, so far as treatment is concerned, to decide 
whether the meningitis is really dependent solely upon 
the panophthalmitis, or whether the removal of the 
eyeball can be held to be responsible for its develop- 
ment. 

All these cases have certain features in which they 
resemble one another closely, and before entering upon 
the discussion of the various points which suggest them- 
selves, it may be of service to make a few remarks on 
each of them. 

Case I. The patient here is a young man, get. 21 years, 
whose eye was injured seven years previously with a gun- 
cap. This caused a traumatic cataract, and the panoph- 
thalmitis, which, directly or indirectly, led to the patient's 
death, was the result of an operation undertaken for its 
removal. 

There is one point which must not be lost sight of, 
and that is the condition of the patient's health. This, at 
the time of the operation, was as bad as it could be. . His 
stepfather stated that his health had completely given 
way lately, and that he was not at all surprised to" hear of 
his death. 

It can scarcely be doubted, in face of a statement of 
this kind, that his system was in the worst condition to 
enable him to withstand a severe febrile disease. The 
eye was suppurating for four days before it was excised, 
and, owing to the globe being accidentally opened, the 



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322 ON MENINGITIS FOLLOWING EXCISION 

purulent contents came into contact with, and infected, 
the recently cut tissues. 

Case II was an old man, set. 72 years, in fairly good 
health, and suffering from a traumatic ulcer of the cornea, 
with a prolapse of the iris. It was by no means a favour- 
able case, but the prolapse was removed, and subsequently 
the lens escaped, and the vitreous protruded. 

The eye was excised three days after it commenced to 
suppurate, and no complication of any sort occurred during 
the operation. At the post mortem there appeared to be 
some old adhesions of the membranes, besides recent lymph 
and pus on localised portions of the convexities of both 
hemispheres anterior to the fissures of Sylvius. There 
was no basal meningitis. 

Case III is instructive, and differs from most of the 
others by the long period of time which elapsed after the 
eye commenced to suppurate until it was excised. The 
patient positively refused to have anything done> and left 
the hospital. It was only the intense pain which she 
suffered in the head which induced her to return and 
submit to having the eye removed. 

By this time her health was severely affected by the 
pyrexia and pain caused by the suppurating eye, and 
although no positive symptoms of meningitis were recog- 
nisable before enucleation of the globe, yet the severe 
headache and general appearance of the patient were 
very suggestive of her being in the early stage of some 
acute disease. The orbital fat was thoroughly infiltrated 
with purulent exudation, and the post-mortem appearances 
left no doubt that at least one way in which the meninges 
had become infected was by direct spread along the optic 
nerve. 

Case IV was a feeble old man, set. 60, who had suffered 
from a traumatic ulcer, and from the history it is quite 
certain that the eye had been suppurating for at least 
three weeks before he was seen, and before it was removed. 
The only complication which occurred during the opera- 



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OF THE EYEBALL FOR PANOPHTHALMITIS. 323 

tion was that the optic nerve was cut very close to the 
globe, but not close enough to open it, nor to allow of the 
escape of any purulent material into the socket. The stump 
was then picked up and cut further back. In this case the 
nerve was found after death to be free from inflammatory 
changes, and the orbital fat was healthy ; there was hardly 
any meningitis seen at the base of the brain, but it was 
most extensive in the convex surfaces of both hemi- 
spheres. 

Case V was an old man, get. 70, who, on account of his 
general feeble state, had a preliminary iridectomy done two 
months before the cataract was extracted. He appeared 
to do quite well for the first four days, and the eye did not 
begin to suppurate until the seventh day after the lens had 
been removed. Everything was done to arrest its progress, 
but in vain, and the globe, was excised 24 days after the 
extraction, and 17 days after it had commenced to sup- 
purate. 

During the excision some of the purulent contents of 
the eye escaped from the extraction wound, and came in 
contact with the recently cut tissues of the orbit. 

The most noticeable thing about the pathological 
changes found after death was the very strong adhesions 
between the membranes and the bone on one side, and 
the brain on the other. There was extensive menin- 
gitis affecting both the surface and also the base of the 
brain. 

There are now on record more or less complete notes 
of many cases in which death from meningitis has followed 
suppuration of the eye-ball, and a paper, published by 
Mr. Nettleship/*" contains a collection of 34 cases in which 
this occurred. Out of this number five recovered after 
having shown well marked signs of meningitis, while 29 
died. Most of these fatal cases terminated in from two 
to four days after the onset of the symptoms, the longest 

* Oplifch. Soe. Trans., 1886, p. 445. 
VOL. XIV. Y 



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324 ON MENINGITIS FOLLOWING EXCISION 

period of time being' eight days after excision, while the 
symptoms commenced in nearly all cases during the first 
48 hours, only four exceeding this time. 

This, to say the least of it, is very suggestive that the 
operation had something to do with it, though it by no 
means proves that infection may not have taken place 
before the eye was excised; and that such a thing is 
possible, besides being highly probable, is shown by the 
fact that some cases are recorded in which death from 
meningitis has occurred after panophthalmitis without 
excision. One such case was published by Mr. Tay.* 

Here suppuration of the left eyeball followed an iri- 
dectomy for chronic inflammatory glaucoma in a woman, 
set. 68, who had undergone the operation for cataract 
extraction some two years before. At the same time that 
this secondary iridectomy was done, some membrane in 
the pupil was torn across. The eye suppurated, and the 
patient died suddenly 13 days after the operation. There 
was extensive suppurative meningitis, the ventricles con- 
tained purulent fluid, and the brain showed many small 
haemorrhages. In the hinder part of the left orbit was an 
abscess containing blood-stained pus. 

This is by no means the only case recorded in which 
meningitis has followed upon a suppurating eye which has 
not been removed, and I am indebted to Mr. Tay for the 
notes of the following interesting case, which was seen by 
him elsewhere. 

Ethel C, set. 10 months, was admitted May 2, 1896, with 
the following history, 

She had always been a healthy child, and had had no pre- 
vious illness. Suckled eight months. Ten days before admis- 
sion the mother noticed that the child's right eye was blood- 
shot. No history of any fall, blow, or injury. She had had a 
cough, and " seemed ill in herself," for two days. 

Present State.— Well nourished, healthy-looking child. Tem- 
perature, 104°. No signs of rickets ; anterior fontanelle o ; pen. 
* Oplil!:. Hosp. Reports, vol. yii, p. 506. 



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OF THE EYEBALL FOR PANOPHTHALMITIS. 325 

Pulse, 140°. Respiration, 48. Frequent cough, dulness, and 
crepitations at left posterior base. Heart and abdomen nil ; no 
cyanosis. 

Right eye injected, especially in circumcorneal margin. The 
right pupii is irregular. There is a yellow reflex from the 
vitreous, and the iris is cloudy and discoloured. 

Treatment. — Inunction of Ung. Hydrag. once a day. 

5o Sp. ammon. co, 
Yin. ipecac, 
Syr. tolu., everj four hours. 

Garagee jacket. Warm, sponging for temperature. 

The next day submucous rales were heard over both lungs. 
Temperature still high. For three to four days there was but 
little change. The signs of broncho-pneumonia continued, but 
the child took its nourishment well. There was no retraction 
of head or belly, and the knee jerks w^ere present and equal. 
The right pupil dilated very irregularly to atropine. 

On May 7 the pulse and respirations increased. The steam 
tent was used ; vinum antimoniale m. vii. every two hours given, 
and leeches were applied over the sternum. 

The respiration became more embarrassed, the cyanosis very 
marked, and the pulse rapid. Liq. strychninas m. iii w T as in- 
jected. Inhalations of oxygen were given. There was some 
diarrhoea, but no convulsions and no retraction of the head. 
The left fundus w r as not examined, and the right could not be 
seen. Child gradually sank, 

Autopsy. — Lungs. Extension "broncho-pneuinonia of whole of 
the left, and the low r er lobe of the right, lung. Much pus in 
the tubes. Plastic lymph on pleura of both lungs. The larynx, 
pericardium, heart, spleen, and kidneys are all noxmial. 

Brain. — Purulent meningitis extends over the surfaces of the 
hemispheres on both sides, and down to the base. There is no 
excess of fluid in the ventricles, and no tubercles. 

11. eye.— The whole of the vitreous is converted into a 
purulent mass. The pupil is very irregular, and the contents of 
the anterior chamber is opaque. The fat around the right 
eye appears to be quite normal. 

This is a complicated case, as it is difficult to be posi- 
tively certain what was the original cause of the mischief. 

Y 2 



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326 ON MENINGITIS FOLLOWING EXCISION 

We have it definitely stated, however, that the eye 
was noticed to have been first affected 10 days before the 
child was brought to the hospital, and that she had only 
been ill in herself for two days, so that the eye affection 
was known to have existed for at least eight days before 
the patient's general health attracted attention. 

She very soon developed signs of broncho-pneumonia, 
but never during the time she was alive was there any- 
thing to point to there being intracranial disease. 

Unfortunately there is nothing in the history to suggest 
the cause of the panophthalmitis, and there was no obvious 
wound discovered. But still one knows how easy it is 
for a baby to injure its eye, and for no one to have 1he 
least idea as to how it was clone. It has frequently been 
suggested that a pin or needle protruding from the mother's 
dress may penetrate the globe, and it is only after the 
development of a traumatic cataract or panophthalmitis 
that anything; is noticed. A similar thing may have 
occurred here, and if the puncture was not actually in the 
cornea, it would certainly have never been recognised 10 
or more days afterwards, but,, nevertheless, the vitreous 
may have become infected. 

There is nothing in this case to suggest the possibility 
that the meningitis or panophthalmitis was secondary to 
the broncho-pneumonia, for iiiflimmation of the eye was 
noticed several days before the. child appeared to be ill. 

We may also exclude general tuberculosis, for the fol- 
lowing reasons. The child was quite healthy and well 
nourished before the fatal illness commenced, and showed 
none of the signs of this disease. Also there was nothing 
found at the post-mortem which suggested it. We are 
therefore driven to the conclusion that the panophthal- 
mitis was, in all probability, the original trouble. 

With regard to the broncho-pneumonia, was this 
secondary to the suppurating eye, or was it an altogether 
independent disease ? 

I am afraid the evidence we have is hardly sufficient 



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OF THE EYEBALL FOR PANOPHTHALMITIS. 327 

to allow of a definite answer being given to this ; most 
probably the two are independent. With regard to the 
origin of the meningitis, however, I think we oan be a 
little more certain. 

It is a well known fact that meningitis, as the result 
of broncho -pneumonia, is one of the rarest complications 
that is ever seen, although the symptoms of the two 
diseases sometimes resemble each other. And when we 
have a suppurating eye which is so closely connected 
with the brain, we must, on the ground of probability 
conclude, that it is, far and away, the more likely of 
the two to cause intracranial mischief. No one has ever 
doubted the fact that suppuration in the middle ear may 
give rise to septic meningitis, and, unless free drainage is 
quickly established, it is a grave source of danger. Avery 
similar condition is present when an eye is suppurating, 
and it is here really the only explanation which will satis- 
factorily account for the sequence of events. 

In the paper by Mr. Nettleship previously referred to, 
three cases are cited in which the eye was not removed. 
Two of them terminated fatally, with all the signs of 
meningitis ; one was caused by needling a cataract in an 
infant, and the other was the result of an extraction, 
but in neither of them was a post-mortem examination 
made. The other case did not prove fatal, but the patient 
had all the symptoms of intracranial inflammation after a 
wound of the eye, causing panophthalmitis. 

These cases I have mentioned simply as proving the 
fact that meningitis may be started by an eye which con- 
tains pus without its having been excised, and the idea 
that it is dangerous to remove an eye in this condition, 
and that when meningitis develops it is due to the exci- 
sion, probably originated from the fact that fatal cases 
have frequently been recorded under these circumstances, 
but because such unfortunate events have occurred, it by 
no means proves that they were necessarily due to the 
operation. 




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328 ON MSNCNGITIS FOLLOWING EXCISION 

Now, in the oases under discussion, I think we have in 
at least one of them a considerable amount of evidence to 
show that the disease was present before the eye was 
excised, and that if it had been left alone the same result 
would almost certainly have followed. I am now allud- 
ing to Case III. 

All the evidence here goes to show that the patient 
was very ill before the eye was excised, and as she was 
suffering from no other disease (the organs of the body 
being found to be healthy), we are forced to attribute her 
symptoms to one of two diseases, either her illness was 
caused entirely by septic poisoning from the shrunken 
suppurating globe or else she was developing meningitis. 
Of course, one is ready to admit at once that occasionally 
a suppurating eye gives rise to veiy marked symptoms, 
but still one would hardly expect the patient to be suffer- 
ing such severe pain in her head, as to entirely prevent 
sleep, and to reduce her to the state of collapse she was in 
when she applied the second time for admission. The 
post-mortem examination fully confirmed this idea. The 
basal meningitis was far too extensive to have developed 
•in 59 hours, this being the time she lived after the excision ; 
and,' further, the orbital contents were so infiltrated with 
purulent material and the tissues were so matted together 
that the eye was excised with the greatest difficulty, and 
a good deal of adherent fat was removed at the same 
time. Again, the meningitis was most marked in the im- 
mediate vicinity of the optic nerve, and the further one 
got from the chiasma the less marked was the inflamma- 
tion. 

Under these conditions it cannot be maintained that 
the removal of the eye had any direct influence upon the 
termination of the case. 

It may be asked why, if meningitis existed, were there 
no acute symptoms until 24 hours after the operation? 

It is a perfectly well-known fact that meningitis may 
be present without acute symptoms, and also that, after 



OF THE EYEBALL FOR PANOPHTHALMITIS, 329 

well-marked signs of the disease have existed, they may 
subside altogether for a time, mid then again rapidly 
develop shortly before death. Such cases are most 
frequently seen in the practice of the general and aural 
surgeons, and as an example of this I will quote a case, 
the notes of which were kindly placed at my disposal by 
Dr. J. R. Limn and Professor Victor Horsley* 

The patient was a male, aged 20, who was admitted into the 
Marylebone Infirmary on November 22, 1887, with the follow- 
ing history. He had been subject to a discharge from the 
ears for 13 months, but it had recently ceased. For the last 
two months he had been feeling unwell, but was not really ill 
until eight days before admission. He then suffered from 
pains all over his head and from constant vomiting. His con- 
dition was as follows : — 

Severe pains in the head. Perspiring freely. Tache cere- 
brale on forehead. Hyperesthesia of frontal region. Papils 
equal, and active to light and accommodation. No paralysis of 
any muscle. Pulse 99. Temperature 104r2°. 

Under general treatment he improved considerably, the 
temperature fell at times to normal, but rose occasionally at 
night. On December 1 he had a good deal of pain in the head, 
and the temperature rose to 102 '8°, and on the following morn- 
ing it was 100*4°. He again improved, and went on well. The 
ears discharged more freely, the headaches were less severe and 
at times disappeared. On January 2> 1888, the discharge again 
ceased, and he complained of a good deal of pain. He was 
drowsy, the pupils were dilated and opisthotonos developed. 
There was no facial paralysis. On January 8 Prof essor Victor 
Horsley saw the patient, and, after an anaesthetic was given, 
he trephined over the mastoid cells, and found considerable 
necrosis of the external auditory meatus. Some dead bone was 
removed, and a drainage tube was inserted. The temperature 
at once fell to normal, and the patient was much relieved. 

On January 12, temperature normal. JSTo pain. Patient 
cheerful and much less drowsy. 

January 20. " Patient has made an uninterrupted recovery 
since the operation. The temperature has only once reached 100°. 
He gets up and walks about, and is doing perfectly well,*' 



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330 ON MENINGITIS FOLLOWING EXCISION 

On February 1 there was a return of the symptoms. At 
first there was vomiting, followed by headache. .Nothing 
serious showed itself until February 12, when the headache and 
vomiting became much worse. There was marked opistho- 
tonos, retention of urine, and severe cramps in the legs. 
Temperature 100°. Pulse 176. Patient gradually became worse 
until February 16, when he developed general convulsions and 
died. 

An autopsy was made, and the following condition was 
found : — 

The membranes at tho base of the brain, and especially 
around the pons, were much thickened, the same inflammatory 
condition extended up the fissure of Sylvius, and the whole 
brain, with the exception of the cerebellum, showed signs of 
general meningitis, pus was present beneath the arachnoid as 
far forwards as the fissure of Sylvius, and the surface of the 
brain between here and the cerebellum was discoloured and 
softened. The lateral ventricles contained a small quantity of 
turbid fluid. Opposite the lumber enlargement and in the 
muscles of the back pus was found which had burst through a 
rupture in the membranes of the cord at this spot. In the 
subarachnoid space, and extending from the medulla oblongata 
to the cauda equina, there was a thick layer of purulent lymph, 
though the inflammation was most marked in that part of the 
cord below the cervical enlargement, The pus extended along 
the sheaths of some of the dorsal and lumbar nerves. 

Now, it is quite certain that this patient was suffering 
from meningitis when first he was seen, but after the 
intracranial pressure had been relieved, the necrosed bone 
removed, and the pus drained, he got so well that he was 
able to get about and appeared quite convalescent ; then 
suddenly, and without any warnings, acute symptoms set 
in, the temperature rose, and death resulted. What it 
exactly was which determined the fatal issue one cannot 
say, but here was a man to all intents and purposes 
rapidly regaining health and losing all his symptoms and 
at the same time he had the most advanced form of 
cerebrospinal meningitis that it would be possible to 
imagine. In the face of a case like this we must admit 



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OF THE EYEBALL FOR PANOPHTHALMITIS. 33L 

that septic meningitis may exist without the ordinary 
acute symptoms. That other forms of meningitis may 
pursue a similar course is well known : to mention, as an 
example, only one case which occurred in this hospital. 

A child, set. 2 years and 10 months, was admitted on 
October 19, 1893, having undergone already three previous 
operations in the left eye for lamellar cataract. The lens was 
opaque and partially absorbed. The child was rather delicate, 
but otherwise in good health. On October 20 the cataract was 
needled under chloroform. At 2 A.M. the following morning 
(14 hours after the operation) he had a convulsion. Tempera- 
ture 100°. This condition gradually got worse, and the tem- 
perature continued to rise, and at 4 p.m. it was 105°. Sponging 
brought it down to 10T4°, but the child's condition did not 
improve, and he died at 9 p.m., being 19 hours after the first 
appearance of cerebral disease. 

At the post-mortem examination there was found much local 
meningitis and a large tubercular mass close to the olfactory 
lobes ; it was adherent to the brain, and so soft as to be almost 
diffluent. The whole brain was cedematous, and the sub- 
arachnoid fluid was turbid. The discs were not obviously 
swollen, but microscopically the optic nerves, and especially 
the nerve sheaths, showed inflammatory changes. The other 
organs of fche body were healthy. 

Tn the case we are considering (No. Ill) there can be 
no doubt but that the intracranial disease was actually 
present at the time that the eye was removed, and there- 
fore the excision cannot be held responsible for the death 
of the patient. All the evidence points the other way, 
and if the patient had consented to having her eye re- 
moved when it first commenced to suppurate there is no 
reason to suppose that she would not have been entirely 
free from danger, and restored to health in the course of 
a few days. 

This case differs materially from the other four in this 
respect, viz., that the meningitis was the result of a direct 
spread backwards along the structures entering and leav- 



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332 ON MENINGITIS FOLLOWING EXCISION 

ing the cranial cavity by the sphenoidal fissure and optic 
foramen, and therefore the part most affected was the base. 
In all the others the surfaces of the hemispheres were the 
most diseased, and the orbital tissues and the optic nerves 
were hardly affected at all, and in Cases II and IV the base 
of the brain was practically healthy ; we must therefore 
look further for a source of infection, for it certainly could 
not have been the result of direct spread by contact. 

The only other way in which a suppurating eye may 
cause infection is through the blood and lymph stream 
returning from it and thus carrying the infective material 
to some other part. 

If now we have a suppurative choroditis it is at once 
apparent that the numerous vessels contained in that 
structure are, owing to their proximity, in great danger 
of becoming inflamed, with the result that septic throm- 
bosis is almost certain to occur. This is of course ex- 
tremely dangerous, as the vessels in the cranial cavity 
can so easily become affected, either by direct spread 
along the veins into the sinuses, or else by septic emboli 
becoming dislodged and being carried into the circulation. 
Both these conditions are not infrequently seen in general 
surgical practice, and pyaemia is occasionally the result. 
It is true, it is extremely rare to get this latter condi- 
tion as the result of panophthalmitis, but then such cases 
are not often left to pursue their course, and it is so much 
easier to drain an eye than to drain the middle ear, with 
the various adjoining sinuses and cells which are enclosed 
in bony walls, and even if such a case as we are consider- 
ing runs its course without interference, the eyeball is sure 
to rupture externally, and thus an exit is found for the pus. 
This, however, will not entirely prevent the mischief, and 
in several of the cases we see that meningitis spreading 
from the vessels on the surface of the brain is produced, 
and here we frequently observe that neither the orbit nor 
the base of the brain is affected to any appreciable 
extent, and often when there is basal meningitis it is 



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OF THE EYEBALL FOR PANOPHTHALMITIS. 333 

nothing like so well marked as that on the surfaces of the 
hemispheres. 

This is precisely what one might expect, and it is 
interesting to find it so frequently present. In the cases 
here recorded, the condition is well seen in Nos. II and IV 
and to a less extent in Nos. I and V. As a consequence, 
we should expect the appearance of the brain to indicate 
that the disease is really of older standing than the symp- 
toms indicated. This is the very thing that at once 
strikes one when making the post-mortem examination. 
It is impossible to believe, for instance, that the marked 
softening and extensive subarachnoid suppuration noted 
in Case IV, could all have come on during the 33 hours 
which the patient lived after the first sign of the mischief. 
It must have taken many days at least to. develop, and 
this was also the opinion of Professor Victor Horsley, who 
very kindly examined the brain with me; the same also 
applies to the other cases. 

In seeking a cause for the meningitis it must be re- 
membered that suppurating eyes are by no means the 
only ones, the removal of which has been known to be 
followed by death from meningitis. A case is reported by 
Dr. A. Dyce Davidson* in which symptoms of menin- 
gitis developed within 24 hours of the removal of an old 
injured eye, which was blind and painful but had not been 
wounded since the original injury four or five years before. 
" She looked somewhat broken down in health, and was 
far from well nourished." She died on the third day after 
the operation in a comatose condition. At the post-mortem 
examination the only thing found besides the meningitis 
was a catarrhal inflammation of the body and cervix of 
the uterus evidently of old standing. Whether this was 
sufficient to cause the meningitis, or whether the two were 
altogether independent one cannot say for certain, but it 
was far more likely that the patient was suffering from 
the meningeal affection, both previous to and at the time 

* Trans. Ophtli. Soc, vol. \i, p. 486. 



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334 ON MENINGITIS FOLLOWING EXCISION 

of the operation, but it was not until the acute symptoms 
set in that the disease was recognised, and this happened 
after the eye had been removed. 

It has been noticed that in some of the fatal cases there 
is inflammation not only of the eyeball but also of the 
orbital tissues, and this was especially well seen in Case 
III. This must very greatly add to the severity of the 
disease, for orbital cellulitis is, in itself, a dangerous condi- 
tion, and such cases which have terminated fatally either 
from pyaemia or intracranial suppuration are within the 
experience of most surgeons, there being, of course, direct 
connection between the brain and the orbit through the 
sphenoidal fissure by means of the numerous nerves and 
vessels passing between the two* 

Obviously the correct treatment in such a condition is 
to provide efficient drainage, either by simple incisions or 
more thoroughly by removing the starting point of the 
mischief, viz., the eyeball. 

There is still another way in which infection can be 
guarded against in the majority of cases, and that is to be 
extremely careful when removing a suppurating eye not 
to allow the contents of the globe to come into contact 
with the recently cut orbital tissues, lest absorption and 
fresh suppuration be the result. 

Now, although there is insufficient evidence in any of 
these five cases to say that the meningitis was started in 
this way, yet we must admit, on ordinary surgical prin- 
ciples, that such a thing should be strenuously avoided, 
and it is hi teres ting to note that out of the five cases here 
recorded, this very thing actually did happen in Nos. I, 
III, IV, and V. 

In Case 1 the sclerotic was accidentally incised behind, 
and the pus then at once escaped into the orbit. 

In Case III the globe was collapsed before it was 
removed, and practically all the contents were squeezed 
out during the excision. 

In Case IV the cornea was destroyed by ulceration, 



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OF THE EYEBALL FOR PANOPHTHALMITIS. 335 

and the contents escaped during the removal of the 
globe. 

Precisely the same thing happened in Case V, where 
the extraction wound was not healed, and it allowed the 
interior of the suppurating globe to escape as the nerve 
was being divided. One can be absolutely certain of 
avoiding this complication by cutting away the cornea 
and completely removing the suppurating mass within 
the globe before doing anything else ; then the conjunc- 
tival sac must be thoroughly disinfected before attempt- 
ing to remove the sclerotic. This practice is always 
adopted by the Editor when dealing with an eye in this 
condition. 

It has been furthermore suggested that the use of the 
irrigator is a source of danger after excision, as the fluid 
used may possibly force pus backwards into the recently 
cut tissues, and acting on this theory, some surgeons 
prefer to dispense altogether with the stream and simply 
allow the socket to bleed freely for a few minutes before 
applying a compress ; in this way, any infective material 
will get washed by the blood out of the orbit instead of in 
the reverse direction. 

These cases, however, do not lend support to this 
theory, fcr in Cases II and V the irrigator was not used, 
and in No. V it was especially noted that the socket was 
allowed to bleed freely for some minutes before being tied 
up. And even in the other cases it is difficult to suppose 
that any infective material was carried backwards, for the 
antiseptic fluid is not pumped in under pressure, and it is 
far more likely both ta destroy and remove any organisms 
of suppuration than it is to aid their development or assist 
their dissemination. If the theory could be proved in the 
case of the orbit, it would be equally true in every part of 
the body, and then there would be an end of irrigation, 
which is, of course, one of the most efficient means of 
cleansing many wounds, raw surfaces, and sinuses. 

There is still another suggestion raised to account for 



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336 ON MENINGITIS FOLLOWING EXCISION 

the cerebral infection. It is urged that the chief danger 
lies in tying the eye up directly after the operation, and 
thus preventing free drainage, and at one time it was the 
custom to place a sponge within the socket so as to pre- 
vent haemorrhage, and to leave it there for some hours. 
This certainly would be a very great danger were it ever 
adopted, but, at Moorfields, such a practice has been given 
up for years. Nothing is ever placed within the lids, and 
troublesome hemorrhage is practically never seen. After 
the excision of a suppurating eye, the first dressing is 
always removed within the first two hours, and nothing 
but a pad of absorbent Gam gee tissue fastened with a 
simple tie bandage is employed afterwards; this is fre- 
quently changed, and the socket is gently washed out 
and bathed with an antiseptic lotion. 

We may summarise the matter, and draw the follow- 
ing conclusions : — 

1. Meningitis may be present for a certain time with- 
out there being sufficient symptoms to enable one to 
diagnose the disease. 

2. Meningitis has been known to follow other opera- 
tions besides the excision of suppurating eyes, and cases 
are also recorded in which the excision of an eye which 
was not suppurating has been followed by death from 
meningitis. 

3. The changes seen in many cases indicate that the 
disease is of older standing than the symptoms would 
appear to indicate. 

4. Infection may occur at any time from an eye which 
is suppurating, and the longer the pus is shut up in the 
eye the greater is the risk, and the greater will be the 
absorption of the products of suppuration. 

5. There are two ways in which meningitis may arise : 
(a) by direct extension along the optic nerve and struc- 
tures passing through the sphenoidal fissure; (&) by in- 
fective material being carried along the vessels. 

6. The sooner the pus is got rid of the better, and if it 



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OF THE EYEBALL FOR PANOPHTHALMITIS. 337 

is thought undesirable to excise the eye, it should be at 
once opened, the contents completely removed, the sclerotic 
thoroughly scrubbed out, and both it and the surrounding 
parts rendered aseptic. Owing to there being no clear 
cornea to injure, a far stronger antiseptic may be employed 
than would be possible if a seeing eye were present. 

7. As the products of putrefaction may have soaked 
into the sclerotic and have infected the surrounding parts, 
it is far better to remove it ; good drainage is then 
insured, and every piece of useless and suppurating tissue 
is removed. 

Judging from -the examination of eviscerated eyes, it 
certainly requires much care and trouble to thoroughly 
remove the whole contents of the sclerotic; frequently 
some pieces of choroid, at least, are left, owing to inflam- 
matory adhesions. 

Between the years 1861 and 1896 there have been 
6,580 eyes excised at Moorfields. 

Prior to 1880 there is no record of a death from 
meningitis after excision, but since then 8 fatal cases 
have occurred, or 0*12 per cent, of the total number of 
excisions. 



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338 



STRIATED OPACITY OF THE COENEA. 
By W. T. Holmes Sptcer. 

The appearance of grey lines in the cornea is fairly 
common, and is found under widely differing conditions; 
from time to time various authors have described the 
lines, and their probable nature has given rise to a good 
deal of speculation. The opportunity of determining by 
microscopic examination the exact seat and nature oi the 
lesion does not occur very often; moreover, the appear- 
ances are very slight, and do not explain all that is seen 
on examination of the affected cornea during life, so that 
we are still not in a position to state dogmatically what is 
the anatomical basis of the grey lines, or whether they 
are all of the same nature. 

The lines appear sometimes as more or less straight, 
and parallel bars of light grey opacity in the substance of 
the cornea; sometimes they are unbranched, sometimes 
they are, or appear to be, branched, or crossed by other 
bars running at different angles ; in some cases the points 
of crossing of the several lines are increased in size by the 
formation of a nodule of opacity where the two lines come 
into contact. The bars, as a rule, appear to be quite solid 
and granular, and may reach a width of about 0*5 mm. ; 
instead of being solid, they are occasionally seen to have a 
double contour, that is to say, each line is made up of two 
distinct lines with a comparatively clear space between 
them ; when this arrangement is present, the appearance 
is very strongly suggestive of a tubular formation in the 
substance of the cornea. (Fig. 3.) 

Many of the cases are traumatic, and present a series 
of fine grey lines running from the edge of the wound 
towards the centre of the cornea. The traumatic variety 
that has excited the greatest amount of interest, and pro- 
voked the greatest amount of discussion, is that which is 



< 



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STRIATED OPACITY OF THE CORNEA, 339 

one of the commonest sequels of cataract extraction. The 
duration of the phenomenon varies between a few hours 
and several weeks. 

For seeing the striated lines properly, focal illumina- 
tion and magnification by a strong lens, or examination 
with the binocular microscope, are more successful than 
direct ophthalmoscopic examination by transmitted light, 
as the lines themselves are generally so transparent as to 
transmit the light without materially changing its direc- 
tion or absorbing any of it ; they therefore either remain 
invisible or are seen only as a thin band of altered light. 

Becker* described the appearances seen in the case of 
a girl who had had a diabetic cataract removed by opera- 
tion, who died two days after ; well-marked striped 
keratitis was present before death. Microscopic examina- 
tion showed a marked widening of tAe tissue spaces in 
the cornea, especially in its deeper layM ; a few lymphoid 
cells were present, but there was no gi^at cellular exuda- 
tion. J 

V. Recklinghausen! described th0 examination of 
another case in which there was widening of the lymph 
spaces of the cornea, especially in the deeper layers. 

Very little is known from actual post-mortem examina- 
tion of the non-traumatic varieties. Deutschmannf 
examined an eye, with detachment of the retina, in which 
there was also striped keratitis. He found the corneal 
spaces at the back of the cornea much widened and filled 
with fluid. 

Nuel§ next suggested, from clinical observation and 
from the examination of a cornea post-mortem, the follow- 
ing explanation. The whole cornea is creased or folded; 
on the summit of the folds, the endothelium suffers a 
solution of continuity, and a non-inflammatory infiltration 

* Atlas des path. Anat. des Auges, 1878, p. 93. Plate 30. 
f Bericht iiber die Versammlung d. Ophtli. Gesellschaft. zu Heidelberg 
1887, p. 124. 6 ' 

X Beitriige zur Augenheilk., vol. 1, p. 43. 

§ Bull, et Memoires de la Soc. Franeaise d'Ophtal., 1892, p. 37. 
VOL. XIV. ' 7 



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340 STRIATED OPACITY OF THE CORNEA. 

of the cornea ensues. He considered that the folds might 
be produced by pressure of/ a bandage. 

This was the starting point of another theory first put 
forward by Hess,* that the folds are not due to a pressure 
bandage, as they occur when the. eye has not been ban- 
daged. From the examination of an excised eye affected 
with striped keratitis, and from a series of experiments on 
rabbits' eyes, he concluded that a widening of the corneal 
spaces was not present, or, if so, in the superficial layers 
only, and that the lines were due to a folding of the 
posterior layers of the cornea including Descemet's mem- 
brane. This folding was due to the alteration in tension 
of Descemet's membrane consequent upon the section. 

Since then Schirmert has confirmed this view by a 
series of experiments on rabbits. He is of opinion that * 
the pathological appearances shown in Becker's sections 
do not explain W clinical phenomena. According to 
Becker, there are^arge numbers of small lymph spaces 
running in various directions through the corneal paren- 
chyma, and crossing one another, whereas clinically we 
see individual streaks several millimetres long by about 
0*5 mm. broad, which commonly do not cross, but run 
at right angles tp the direction of the wound in a more 
or less parallel direction. Schirmer next deals with the 
striated opacities T^vhich appear in keratitis with hypopyon, 
and he thinks tljiese are caused by folds in Descemet's 
membrane, for the following reasons.' By transmitted 
light they appear not as opaque lines but as clear bright 
streaks; they therefore depend on a difference in light 
reflection. They occur at one level only, that of Desce- 
met's membrane ; they radiate from the edge of the ulcer, 
an arrangement which does not exist in any of the natural 
spaces of the corneal parenchyma. They are, therefore, 

* V. G-raefe's Archiv, 1892, vol. iv, p. 1. Abstracted in Ophth. Rev., 
1893. 

f T. G-raefe's Arcliiv, 1896, vol. iii,p. 1. Ueber Faltungstriibungen der 
Hornhaut. 



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STRIATED OPACITIT OF THE CORNEA. 341 

clinically identical with the striae which appear after 
cataract extraction. 

There are, then, two main ^explanations of the occur- 
rence of striated opacity of the\ cornea ; according to the 
most recent one, it is held thafe the lines are due to folds 
of Descemet's membrane, together with the deepest layers 
of the cornea. According to th<i older view, the lines are 
due to the formation of spaces between the fibres con- 
stituting the substance of the corliea ; such spaces being 
formed by an oedema or exudation lof fluid into the cornea 
consequent on local congestive causes in the cornea, or in 
the parts immediately around it. Li is not necessary for 
the fluid to be opaque in order to mkke itself visible, the 
different density of the fluid contained within the spaces 
would act on light reflected from its surface in such a way 
as to differentiate the spaces from t]^ adjacent normal 
tissues. 

If it be granted that such an explanation is possible, 
we are still ignorant of the manner l of origin of such 
tubular spaces, whether they are duetto a mechanical 
separation of the fibres of the corneal by the pressure of 
fluid exerted on it, or whether they are caused by an 
exudation into already existing spaces. ; 

There are two kinds of spaces in the normal corneal 
substance which may be readily demonstrated. By insert- 
ing the nozzle of a very fine syringe into the substance of 
the cornea, and injecting fluid under very low pressure, a fine 
system of cell spaces can be demonstrated, communicating 
with one another by extremely delicate tubes, Reckling- 
hausen's canals ; these cell spaces contain the corneal 
corpuscles which communicate by processes with similar 
processes of adjoining cells ; these cell spaces are much 
flattened out, and are very thin ; the processes, too, have 
no regular or definite arrangement. If the injection fluid 
be thrown in under great pressure, or if it be a much 
denser fluid like liquid mercury, or, still better, if air be 
injected, it passes between the corneal fibrillar and forms 

z 2 



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342 STRIATED OPACITY! OF THE CORNEA, 

spaces there, lying in the' direction of the fibrillse, so that 
an appearance of minute mibes running parallel to one 
another in the cornea is fpund. If the fluid be injected 
into the cornea at differer/it levels, so that more than one 
stratum is attacked, the tu/bes formed in successive strata 
will be found to be at rigVit angles to one another. This 
observation was first mad/e by Bowman, and the tubes so 
formed have always b/aen known as Bowman's corneal 
tubes. The injection 111 ways stops at the margin of the ; 
cornea, where the tissiie becomes denser as it passes into 
the sclerotic, whereas i Recklinghausen's canals are con- 
tinued into the cell spaces of the sclerotic. 

No other lymphatic spaces or vessels are discoverable 
unless the channels J in which the nerves run, which are 
lined with flattened? cells and are indirectly in connec- 
tion with the cellfcpaces. can be considered as being of 
this nature. ThesBfchannels branch very much, and form 
a fine, close network near the anterior surface of the 
cornea.* 

It is clear, fr<^i the description here given, that the. 
striated lines of opacity cannot correspond with either 
Recklinghausen's tubes or with the distribution of the 
corneal nerves, inasmuch as they run in parallel lines,- 
which do not anastomose or branch freely ; on the other 
hand, they may hi well represented by Bowman's tubes, 
which run a straight parallel course and do not anasto- 
mose. The further fact that the lines of striated opacity 
do not appear to reach the margin of the cornea agrees ; 
with the arrangement of Bowman's tubes. The occur- 
rence of occasional crossing of the lines, or of a distinct, 
network of lines, would be explained by the oedema 
attacking more than one layer of the cornea. 

The anatomical cause of the lesion is then narrowed 
down to the two factors— folds of Descemet's membrane, 
and a fluid distension or oedema of the interfibrillary 
spaces of the posterior layers of the corneal parenchyma. 

* Quain's Anatomy, 1894, vol. iii, part 3, p. 22. 



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STRIATED OPACITY OF THE CORNEA. 343 

From an examination I have made of sections of the 
cornea in eyes which were Inot affected with striated 
opacity, it appears that such wrinklings are not un- 
common, and are probably produced by post-mortem 
changes, or artificially by manipulation during the pre- 
paration of the specimens. 

Thus, in two cases of melanotic sarcoma of the iris and 
ciliary body, in which there was no striated opacity seen 
during life, there were very well marked folds of Desce- 
met's membrane ; in one of these teases there were about 
six regular folds, and in the other mere were twelve very 
deep folds ; some of the sections i\ the latter case were 
cut very obliquely, so that the K>Ids also were cut 
obliquely, and could be seen for some distance along the 
back of the cornea. In another case^ of sarcoma of the 
choroid with secondary glaucoma, Descemet's membrane 
was finely and evenly raised into twelve folds, situated at 
about equal distances along its whole extent; in this case 
there was, at any rate, no marked appearance of striated 
opacity during life. In all these casll there had been 
marked increase of intra ocular tension noted during life, 
and the folds were probably caused by the relaxation of 
the over-distended membrane. In another case of sup- 
puration in an old glaucomatous eye there were a few 
deep folds, into which the hypopyon mass in the anterior 
chamber was dove-tailed; these folds had probably the 
same cause. In this case, striated opacity may have been 
present during life, but the cornea was too opaque for it * 
to be seen. In a case of perforated ulcer with hypopyon, 
in which the cornea was also very opaque, there were very 
gross folds of Descemet's membrane close to the seat of 
perforation; in this case, too, the hypopyon mass was 
similarly folded, and applied to the elevations and depres- 
sions of the cornea. 

On the other hand, the control experiments of Hess 
and Schirmer seem conclusive as to the wrinklings being 
the cause of the opacity in their cases; in those rabbits' 



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344 STRIATED OPAC1TY/0F THE CORNEA. 

/' 

eyes in which striated opacity was present, the wrinklings 
were present, but in the conjjrol cases treated in the same 
manner, in which there \yas no striated opacity, the 
wrinklings were absent. } 

In Case I (p. 347), in which a piece of glass was driven 
with great force into the £ye, from the bursting of a soda- 
water bottle, on the clay after the accident there was found 
a very oblique wound df the cornea; this was followed 
soon after by the appearance of four or five lines of 
striated opacity, extending from the neighbourhood of the 
wound into the corneal substance (Fig. 2). The eye was 
afterwards excised arJl hardened in formol ; the piece of 
glass had gone through the lens, and was firmly imbedded 
in the ciliary region. Sections of the cornea were made 
across the direction /'of the striated opacity. One or two 
shallow depressions' were found in Descemet's membrane; 
the larger of these, however, seemed to correspond with a 
fold of the whole cornea, as it could be seen on the surface 
of the section ; it is probable, therefore, that it was an 
artificial fold, du%to manipulation (Fig. 1). There was 
some widening of the interfibrillary spaces of the cornea, 
near its posterior surface ; four of these spaces were very 
large, and corresponded in position with the lines as seen 
during life. 

In this case there were both folds of Descemet's mem- 
brane and also widening of the interfibrillary spaces, but 
the latter cause seemed to fit in better with the appear- 
ance seen during life than the folds in the posterior 
limiting membrane. 

Even if the wrinkling of Descemet's membrane is 
proved to be the cause of the striated opacity where a 
corneal section has been made, it still remains to be seen 
whether the striated opacity occurring under other condi- 
tions is satisfactorily explained by this cause. In many 
of the examples of striated opacity occurring without 
injury, associated with inflammations of the anterior part 
of the uveal tract, the individual lines in the cornea, as 



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STRIATED OPACITY! OF THE CORNEA. S45 

seen under high magnification, seem to possess an actual 
tubular structure. They haie a very definite double 
contour, with a comparatively clear centre, suggesting 
very strongly the two limiting walls of a tube with a 
central lumen (see Fig. 3). \ 

It does not seem possible tha\t the folds in Descemet's 
membrane, as seen under the njicroscope, could, under 
any circumstances, appear as double contoured lines, 
whereas the distension of spaces yn the cornea gives a 
very reasonable explanation of the Appearance. 

I have collected all the cases in which I have made 
notes of striated opacity observed in the cornea during the 
past two years, and it seems worth vfhile to put them on 
record. They do not include any or* the cases in which 
it has appeared after cataract extraction, because these 
appear to stand by themselves, they are well known, and 
present a fairly constant appearance. I may say that it 
is the experience of several house surgeons at Moorfields, 
who have the opportunity of watching large numbers of 
cases under the hands of different operators, that striated 
opacity after cataract extraction occurs for a limited time 
in a very large percentage of extractions, but the lines 
soon clear up. According to their experience, it is more 
common where there has been any difficulty in removing 
the lens, or where much manipulation of the corneal flap 
has taken place during the operation. 

My cases are 21 in number; of these, 7 were due more 
or less directly to traumatic causes, the remaining 14 had 
no such cause. 

It is remarkable that, with the exception of the second 
and third cases, there was in every one marked evidence 
of inflammation of the uveal tract, shown generally by 
iritis, or, where that was absent, by deposit on the back of 
the cornea. In the second case, atropine had been used 
before the pa+ient was seen, and, in the third, there is no 
note as to the condition of the iris ; so that it may be 
assumed that inflammation of the anterior part of the 



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346 STRIATED OPACITY/ OF THE CORNEA. 

uveal tract is, if not always present, an extremely common 
occurrence. Further, that iveitis and striated opacity of 
the cornea, if they do not i^and to each other in the rela- 
tion of cause and effect, halve a very intimate relationship, 
is shown by their locality in many instances; if one 
section of the cornea has striated opacity, the correspond- 
ing part of the iris is the/ most congested, as shown by its 
resistance to weak mydr/iatics (Cases XIV and XV). The 
reverse process of a congestion of one section of the iris 
accompanying an ulce ; t of or injury to the corresponding 
part of the cornea, as /is. well known, is of frequent occur- 
rence. In the simpler cases, where an injury was the 
exciting cause of tlfe striation, and where treatment was 
delayed, posterior s^nechise formed, but,, where the con- 
gestion of the cili/ary zone was relieved by atropine, 
the striated opacity at once disappeared. It is probable, 
therefore, that th<i striated opacity is an oedema of the. 
cornea depending /on a congested or inflammatory condi- 
tion of the anterior part of the uveal tract. This oedema 
may accompany all forms of anterior uveitis, gonorrhoea! 
iritis (Cases VIII, IX, XI) ; syphilitic iritis (in Case XV it 
was the first manifestation of the iritis before the forma- 
tion of synechias) ; iridocyclitis '(Cases XIII, XIV), inter- 
stitial keratitis with irido-cyclitis (Cases XVI, XVIII), and 
tubercular iritis (Case XXI). 

Cases XVI, XVII, XVIII, and XX present quite charac- 
teristic features, and seem almost to stand in a group by 
themselves. They are the only instances of which I have 
notes, but I have seen other cases presenting identical 
features. They have most of the characters of interstitial 
keratitis, but it is that form which occurs in adults who do 
not show any of the other signs of hereditary syphilis. 
There was also no certain history pointing to acquired 
syphilis in any of them. The patients are mostly women 
broken down by overwork, want of rest, or trouble; there 
is cyclitis or irido-cyclitis, which runs a very chronic 
course. The first corneal signs are striated opacity, which 



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STRIATED OPACITYV OF THE CORNEA. 347 

is arranged in vertical lines runining nearly across tlie cornea 
from its upper to its lower blorder (Fig. 6). This is fol- 
lowed by the formation of mactylse in or near the centre of 
the cornea; sometimes these i macules leave the centre 
free, and form a pericentral bamd of opacity, the keratitis 
centralis annularis of Vossius. Ljater on in the course of 
the disease some vessels may groV in from the periphery. 
The course of the disease is ve^ry chronic, lasts many 
weeks, and finally clears up or leaves a more or less per- 
manent opacity. This appears to b)e the same affection as 
that described by Fuchs as keratitis ^profunda and by Arlt 
as keratitis rheumatica. The striated opacity does not 
appear to last more than a few weeks] and is replaced by 
the more lasting macule ; it must ybe regarded as an 
oedema, produced by the congestion of the ciliary region. 
The arrangement of the vertical lines \s very remarkable 
and difficult of explanation. The question suggests itself 
whether this arrangement is not due tip the pressure of 
the lids on the oedematous cornea, as\the appearance 
much resembles the arrangement of the nieibomian glands 
in the lid. as seen from behind. ^k 

Finally, if the appearance in questipn be due to folds 
of Descemet's membrane, or, as I canned help thinking, to 
an oedema of the posterior layers of t'he cornea, it cer- 
tainly, with the knowledge we at present possess,' should 
not be looked on as an inflammatory affection, but as 
possessing a secondary and rather mechanical nature ; for 
this reason, I have, in the title of this paper, discarded the 
term "keratitis striata," implying its inflammatory nature, 
for " striated opacity of the cornea," which leaves its origin 
a more open question. 

. Case 1-— Ellen D., »t.37, came to the Metropolitan Hospital 
with a recent wound of the cornea, caused by the bursting of a 
lemonade bottle on March 22, 1896. I first saw her about 14 
hours after the accident. There was then a triangular oblique 
wound of the cornea, penetrating the anterior chamber ; it had 
the appearance of a triangular flap, with its apex upwards • it 



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348 STRIATED OPACITY OP THE CORNEA. 

was in complete apposition ;'/ there were about six lines of 
striated opacity in the deepesjt part of the cornea, extending 
upwards and downwards in both directions into the cornea, at 
right angles to the direction of the wound (Fig. 2) ; the 
cornea was generally hazy /all round the wound for a short 
distance. No foreign body was seen, and the lens appeared 
clear. / 

On March 26 the woxind was healed ; there was a very 
small adhesion of the iris to the edge of the wound. What 
appeared to be a transparent body with a bright reflex appeared 
to be lying partly in front of the iris and partly in the pupil. 

On April 4, a week /later, the eye quiet and healed ; there is 
now undoubtedly a pi^ce of glass imbedded in the lower part of 
the lens. A periphe/ral corneal incision was made, but the 
piece of glass could n|ot be moved. The patient's consent had 
not been given for j removal of the eye; it was accordingly 
closed up. 

On April 8 the wound of the incision was perfectly healed, 
but there were striated lines still running from the old wound ; 
enucleation was advised. The patient's Meeds would not 
consent, and she left the hospital. She then went to Moor- 
fields, and saw M|^Lawford, who advised her to have the eye 
removed. 

She returned to the Metropolitan, and I excised the eye on 
April 13. On opening the globe, a long sharp spike of glass 
was firmly imbedded in the ciliary region ; it was lying across 
the lower part of the pupil, and passed beneath the iris on the 
opposite side. 

The cornea was removed, hardened in formol and alcohol, 
imbedded in celloidin, cut, and stained ; the sections were made 
across the direction of the lines of opacity. 

On examination (Fig. 1) there was a long oblique wound of 
the cornea running across the section ; it was completely 
healed for the greater part of its length, but in one or two 
places there were a few groups of cells lying in the course of 
the wound. In the part of the cornea to the left in the section 
there is one definite fold of Descemet's membrane, and another 
slight wave ; the former of these seemed to be associated with 
a very definite fold of the anterior part of the cornea, and, if so, 
was probably an accidental crease of the whole cornea ; in the 



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STRIATED OPACITY IOF THE CORNEA. 349 



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right-hand part of the section tEiere were one or two very 
shallow waves of Descemet's menibrane, which coald not be 
called folds. In the substance of\ the cornea just above the 
crease in Descemet's membrane in 1 the left-hand part of the 
section there were two clear spaces lin the cornea, produced by 
a separation of its fibres ; just above the end of the wound 
there was a larger clear space, and farther to the right, on the 
other side of the wound, there were) three very considerable 
spaces in the back of the cornea, close to Descemet's membrane, 
produced by a • separation of the corneal fibres. The cornea, 
away from the neighbourhood of the wound, was free from 
folds and clear spaces. 

\ 

Case 2. — Striated opacity after injury by a chip of granite. 

Thos. R. (Met. 610), set. 32, came to the Metropolitan 
Hospital on December 12, 1894. He was struck by a chip of 
granite four days before, and went at once td Moorfields, where 
he received treatment. \ 

When seen there was a longitudinal wound of the left 
cornea, extending down and out from the centre nearly to the 
periphery; it was superficial in its whole extent. On the 
surface there were some grey-yellow granular clots, probably 
granite dust. Extending upwards and downwards from tbe 
wound were about 10 or 12 grey opaque lines, running at right 
angles to the direction of the wound. The pupil dilated well, 
and there was no iritis. Under atropine and a compress the 
wound healed completely in a week, leaving a superficial scar; 
on December 19 the striation had quite disappeared. 

Case 3.- — Striated opacity without wound after injury. 
Jane B., aat. 23, employed at mineral water works (Met. 
458), came to the Metropolitan Hospital on August 15, 1894, 
having got some potash into the eye five days before. There 
was no abrasion of the epithelium ; there were three lines of 
granular-looking opacity lying deep in the cornea; they ran 
from close to the upper border directly downwards to about the 
middle, and appeared to be branched or joined together by 
three obliquely running lines. They were all situated in the 
deepest layers of the cornea. 



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350 STRIATED OPACITY OF THE -CORNEA.." 

She had a physiognomy cMa^act eristic of hereditary syphilis 
there were many radiating .(scars at the angles of the mouth, 
and her upper central incisoy teeth were deeply notched, so that 
it seemed probable that th'p grey lines were the beginning of 
an attack of interstitial keratitis. 

However, with simple ) atropine treatment, when she was 
seen a week later, the eiye was quieter, the grey lines had 
almost disappeared, leaving a number of grey dots in their 
former situation. / 

i 
Case 4. — Striated opacity' of cornea with iritis, after injury with 
'• a chip of iron. 

J. J. M., set. 43. /September 1, 1894. 

Struck in L. eye if our days before by chip of iron. Ulcer in 
lower outer part o| the cornea, with about five grey lines 
extending from it into the substance of the cornea There was 
iritis, and several posterior synechias, but no hypopyon. 

Cleared up rapidly with atropine and rest. 

Case 5. — Striated i opacity with iritis following ivound of cornea. 

(Fig. 4.) 

James B., set. 61, seen at Moorfields, October 20, 1894, 
was struck in the left eye by a French nail four weeks ago ; 
there is a wound at the lower and inner part of the cornea. 
Some distance to the inner side of this there is an almost 
vertical broad band of striated opacity, with several smaller 
bands running at right angles to it, but not all of them joining: 
it ; it is not possible to make out any difference in level, but all 
the lines are deep in the substance of the cornea. There was 
still some iritis present, and there were posterior synechias at 
the lower and inner part, opposite the wound. 

After simple treatment the ulcer healed, and the opaque 
lines quickly cleared. 

Case 6. — Striated opacity of cornea with iritis, following a wound 
by a thorn bush. 

November 7, 1895. T. S. B, (I, 225), male, asfc. 45, was 
cutting clown a thorn bush 48 hours ago, when a piece of 



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STRIATED OPACITY! OF THE CORNEA. 351 

\ 
thorn flew up and struck him a \smart blow on the face and 

right eye. . \ ■■. 

There was a moderately deep wWnd of the cornea at the 
lower inner quadrant, with a slight amount of haze of the 
corneal substance near it; on magnification three or four opaque 
lines were seen to extend upwards, and the same number down- 
wards, from the wound ; it is not possible to say whether these 
start from the level of the wound oij* from a deeper level, but 
they are deep in the cornea. They do kot seem to be continuous 
from one side of the wound to the other, as they do not corre- 
spond entirely. 

There was some iritis ; he had had atropine used by his 
doctor, but the pupil would not dilate fully. 

This patient was not seen again ; siknple treatment was 
advised with atropine and rest ; he probably recovered. 



Case 7. — Lime burn of cornea and conjunctiva ; superficial loss of 
substance. Striated opacity of cornea ; iritis. 

\ 
Edwin B. .(Met. 504), first seen September 26, 1894. 

Mb. 56. He had got some plaster into his\ right eye three 
weeks before. 

There was loss of epithelium over a rounded area at the 
lower part of the right cornea ; it was healed over the greater 
part of its extent. Pupil, small, inactive; posterior synechias ; 
there were lines of striated opacity, partly in the clear cornea^ 
partly running behind the injured area ; their direction was 
vertical. 

He was seen again a week later, but there was no change,. 
He was not seen again. 



Case 8. — Relapsing iritis with striated keratitis. (Fig. 3.) - 

James W., 44, electrical engineer, Holloway, came under 
the care of Mr. Nettleship, at Moorfields, in September, 1893. \ 

September 30, 1893. L. became painful and inflamed 
eight days ago; has had mydriatic, which relieved the pain. 
Had gonorrhoea nine years ago, was laid up with rheumatism 
after in right hip for three months ; has had good health since,, 




352 STRIATED OPACITY OF THE CORNEA. 

Had a cold in the eye 18 nWnths ago, which only lusted a few 
days, but felt like this attache ; no rheumatism since. 

R. 6/6. No Hm. ; L. 6/60. 

L., many posterior syne/chiae with uveal pigment on lens cap- 
sule. Striated keratitis in the form of delicate white lines 
radiating generally from the centre of the cornea ; when mag- 
nified these lines show a clouble contour, the space between the 
lines being comparatively clear; there are grey opaque dots in 
other parts of the corne^ ; the lines are highly suggestive of a 
tubular structure. Treatment : atropine, iodide and bicarb- 
onate of potassium. / 

October 7, 1893. J*upil widely dilated ; much of the pig- 
ment on the lens capsule has disappeared, the lines are fainter, 
and the tubular appearance less marked. 

October 14, 1893J All cleared off. 

January 31, 1894. Relapse in same eye; presents same 
characters of iritis with grey lines, chiefly from above to centre 
of cornea. 

February 10, 1894. Has cleared. R. 6/6. Hm. 1 D. ; 
L. 6/18. c. + 1ST). = 616. 

March 3, 1894/ R. relapse. Attack lasted three weeks. 

May 22, 1895, Relapse in R. 

Case 9. — Iritis with striated keratitis. 

Thos. H., set. 44, Theberton Street, Islington, carpenter, 
came under the care of Mr. Nettleship, at Moorfields, in June, 
1894. 

June 9, 1894. L. inflamed one week. Similar attack four 

years ago. 

Never rheumatic fever. Frequently has rheumatic pains in 
shoulders. Had gonorrhoea many times when young, last time 
20 years ago. Never syphilis* 

R. 6j6. No Hm. 

L., p. inactive, cornea not clear. Posterior synechia?. Pupil 
does not dilate with atropine. Corneal epithelium rough, grey, 
with dark clear places in the grey part. There are also a 
number of double contoured lines in the corneal substance, 
radiating mostly from the centre to the periphery ; they are not 
of uniform size, and are broken up in places into isolated dots. 



1 



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STRIATED OPACITY\ OF THE CORNEA. 353 



Treatment. — Atropine, salicylates and alkalis. 

Jane 16, 1894. Pain gone, P?upils evenly dilated, but not 
widely ; lines in cornea much, fainter, but still present. Some 
very fine dots on back of cornea. \ 

Jane 30. 1894. Pupil never quiue circular ; some posterior 
synechiae. Lines in cornea gone, also\dots on back of cornea. 

August 11, 1894. R. 6/6 ; L. 6j6\ No Hm. c + 1 D. = 
J. 1, good range. 

Case 10. — Iritis with striated tones in the cornea. 

Catherine M., ast. 62, came to Moorfields on May 9, 1896. 

Five weeks ago tbe rigbt eye became inflamed ; there was a 
vague history of an injury to her head, nit to tbe eye; about a_ 
week after she noticed tbe right eye was ih flamed. 

Both pupils were partly dilated ; she h\ad bad a mydriatic 
from her doctor. The rigbt iris was discoloured, but there 
were no adhesions present; there was a glood deal of uveal 
pigment on lens capsule. ) 

T., E. slightly less than L., but both ^re within normal 
limits. i 

Well marked striated opacity of cornea, several lines crossing 
one another, some at right angles, some obliquely. 

Y. R. 6/36. Not improved ;V.L,c + lD. = 6/6. 

May 23. Two weeks later. The pupil is widely dilated; 
some uveal pigment present on lens capsule ; the striated lines 
have quite gone, but there is a good deal of deposit on the back 
of the cornea. 

Case 11. — Relapsing iritis of gonorrheal origin; striated opacity 
of the cornea, 

Arthur W., aefc. 34, painter, had the fourth attack of iritis 
in R. eye in August, 1894. He had had two attacks in L., first 
attack during rheumatism, which was called gonorrhceal, ten 
years ago. 

R. posterior synechia ; general haze of epithelium of cornea. 
A few faint lines of striated opacity in cornea. 

L. Old posterior synechias. 



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354 STRIATED OPACITY OF THE CORNEA. 



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Case 12. — Iritis with! striated opacity in cornea. 

William E., aged 42, seem at Moorfields January 5, 1895.. 

The right had been inflamed three days. First attack. 

No cause known. No rheumatism. No syphilis. 

Posterior synechia ; uyeal pigment on lens capsule. Surface 
disturbance of corneal Epithelium; double contoured lines of 
opacity running in various directions through the cornea, and 
crossing one another. 

Case 13. — Iridocyclitis with striated keratitis. 

Emily D., sat. 27, came under the care of Mr. Nettleship, at 
Moorfields, on Auguslj 8, 189G. 

The left eye had^een inflamed a week. She had had good 
health always, except pleurisy eight months ago. Had not had 
rheumatism. She 4as married; no family; no miscarriages. 
Never sore throat nor skin eruptions. Family history, nil. 

R. 6/6. Hm. /l D.; L. 6/24. Not improved. 

L. Much corneal haze, with grey lines seen under high 
magnification, running for the most part vertically. Also a 
good deal of deposit on the back of the cornea — keratitis punc- 
tata. Iritis with many synechias Physiognomy good. Teeth 
nil. 

Case 14. — Iridocyclitis with striated opacity of the cornea. 

L. C, male, aged 27, cabinet maker, seen at Moorfields on 
February 6, 1895. 

The right eye had been inflamed one week; it was the first 
attack. Was in London Hospital six month ago, and spat 
blood ; had cough. 

Looks .thin, pale, delicate. Never had any venereal disease. 

There is much congestion of the right eye ; there are two 
very gross lines of striated opacity of the cornea at the upper 
inner quadrant; one of them is almost a mm. broad. One 
broad posterior synechia at the upper inner part of the iris. 

February 20. A fortnight later; the eye is much quieter,, 
the grey lines are much less definite now, there is abundant 
deposit on the back of the cornea. 



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STRIATED OPACITY \0F THE CORNEA. 355 

. \ 

Case 15. — Striated opacity 'of the aprnea occurring as the first 
manifestation of Syphilitic Iritis. (Fig. 5.) 

Walter GL, est. 39, came under care of Mr. Nettleship on 
October 31, 1896. The sight of the\R. bad been failing a few 
days. 

There were some striated lines in the cornea, one running 
rather horizontally, and three others radiating from the centre 
of the 0. At the lower part of the Cornea there is some fine 
epithelial opacity. \ 

The pupil acts to light, but the -iris appears to be dis- 
coloured, perhaps owing to the baze of media. It -dilates well 
with atropine, but less quickly at the lower part. Tbere are 
no synechia, no deposit on cornea, nor on lens capsule. 

He is anseniic ; he has a papular syphilide on his face now ; 
on body also ; had primary sore aboat three months ago ; has 
had mercurial treatment. Treatment : atropine, pil. hydrarg. 
c cret., et ipecac. ^ 

November 7, 1396. A week later; the pupil is dilated, but 
not evenly ; there are synechias now ; the striated opacity has 
almost disappeared. 

November 14, 1896. The congestion has subsided entirely i 
the striated opacity has gone ; the pupil is evenly dilated. 

Case 16. — Sloio cyclitis toith interstitial keratitis in an adult 
beginning as striated opacity in the cornea. (J?ig- 6.) 

Ann D., ast. 47, came under the care of Mr. Gunn on March 
3, 1895. The left eye has been inflamed six weeks. She cannot 
account for its onset, except that she was much frightened 
during a severe thunderstorm just before the eye became bad. 
Apart from the eye, her health is, and has been, very good. 
She has been s abject to headaches ; she had influenza a year 
ago. She is not rheumatic ; she has never had any skin erup- 
tions nor sore throat. Has four children alive ; the third and 
fourth pregnancies miscarried. 

Physiognomy good. Teeth lost. 

R. 6/6 no Hm. Cornea n. 

L. There is surface irregularity of epithelium of cornea ; 
not much photophobia. There is a pericentral opacity of the 
VOL. XIV. 2 A 



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356 STRIATED OPACIT,V OF THE CORNEA. 

/ 
cornea, the central part corresponding to the pupil is compara- 
tively clear, Keratitis centralis annularis (Vossius). The whole 
cornea is marked with gre^, vertical lines about 12 in num- 
ber, running almost its whole length ; the lines are deep in 
the substance of the cornea, and appear to run quite inde- 
pendently of the pericentral grey opacity. There are, also, 
some dots of deposit on the back of the cornea, and some 
larger, yellow grey areas which may, from their appearauce, 
either be deposits on the' back of the cornea, or opacity of its 
substance. / 

The iris appears n., and dilates well. Tn. 

On March 20, 17 days after, the pericentral opacity is less 
marked, the vertical lines of striated opacity appear wider, but 
are otherwise unchanged. There is a vascular crescentic area 
at the upper border of the cornea, and one at the lower. 

A fortnight later there was no material change. 

May 8. There la now uniform interstitial opacity of the 
whole upper part oi the cornea, prolonged downwards as a thin 
band to the lower margin ; there are some vessels in this area of 
opacity which seems to have resulted from the extension of the 
upper vascular crescent downwards. The annular opacity and 
the vertical lines have entirely disappeared. P. wide. ISTo iritis. 

December 10, 1895. The inflammation has gradually sub- 
sided. There is now general dense opacity of the whole central 
region of the cornea, with fine, irregular, thin lines running in 
various directions, and vessels entering from the periphery. 
The epithelium seems to be much hypertrophied. There is still 
a good deal of deposit on the back of the cornea. 

Case 17. — Iridocyclitis with vertical lines in the cornea. 

F., ast. 60. Seen March, 1895. Irido-cyclitis ; second attack ; 
good dea] of deposit on back of cornea. Many posterior syn- 
echias; about five lines of striated opacity running completely 
across the cornea in a vertical direction. 

Only seen once. 

Case 18. — Interstitial keratitis preceded by striated opacity. 
Mary P., set. 28, came under the care of Mr. Silcock at 



1 



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STRIATED OPACITY OF THE CORNEA. 357 

Moorfields on September 29, 1896. The R. had been inflamed 
four weeks ; first attack. Had had neuralgia R. side of face 
for -a month. Much broken down from trouble and" want; of 
rest ; had been sitting up with, her baby for many nights ; the~ 
baby afterwards died of bronchitis. 

There were a large number of lines running vertically 
almost the whole length of the cornea; much deposit on the 
back of the cornea. ISTo iritis ; p. dilates well. 

Teeth, physiognomy good. No history of skin eruptions nor 
sore throat. Has two children alive, one set, 6, one set. 3 ; 
her eldest child lived three months, the second three-quarters 
of an hour, the fourth was stilhborn, the sixth died, a month 
ago, at 10 months. 

October 29. The striated lines have disappeared entirely ; r 
there are now a number of grey maculae in the substance of 
the cornea with soft edges-, typical of interstitial keratitis. 
Much keratitis punctata. 

Case 19, — Interstitial keratitis, striated. 

John B., get. 33, bootmaker, Brockley. 

May 31, 1893. L., surface roughening of cornea, general 
epithelial elevation ; deeper interstitial opacity at lower outer 
part of cornea. There are stride running from near the centre 
of the cornea to the periphery, crossed by other striae running 
somewhat irregularly. Much circumcomeal congestion, with 
large episcleral vessels. JSTo iritis, both pupils active. Tn, 
He thought he was rheumatic. 

Paper headed selero-keratitis, treated, atrop. fomentation, 
salicylates. 

After a month the opacity had become more general (iron 
instead of salicylates). After another month had blisters and 
KI, and then began to improve. 

August 16. Attack at an end. 

September 23. He continued the iodide; the R. other eye 
has begun ; epithelial haze, upper part of cornea. 

October 11. R. Interstitial pericentral ring of corneal opacity, 
with much epithelial irregularity, and some straggling surface 
vessels. 

November 8. Quiet. Haze of R. cornea still present. 

2 A 2 



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358 STRIATED OPACITY OF THE CORNEA. 



Case 20. — Interstitial striated keratitis. 

Eliz. H., 9et. 33, Titsey, dressmaker, unmarried. R. began 
five months ago. , L. one week. 

January 14, 1893. R. Severe interstitial keratitis with great 
vascularity, and central opacity of cornea ; (has been taking KI 
and Hg) ; the whole of the upper and central parts of the 
cornea are opaque, with fine ramifying vessels in its sub- 
stance. She thinks it is getting clearer. 

L. Began last week with congestion and photophobia. There 
is fine epithelial swelling in form of small elevations. Beneath 
the surface there are long-waved lines of striated keratitis 
running in a vertical direction nearly the whole distance across 
the cornea. 

There is iritis with posterior synechiee present as well. 

History inconclusive. 

Physiognomy nil. Upper central incisor teeth lost. 

Case 21. — Iritis, probably tubercular, with striated opacity in the 

cornea. 

Peter B., set. 33, coppersmith, May 12, 1894, came to Moor- 
fields. L. had been inflamed three or four days. He had got 
a piece of coke into it— a frequent accident. It was removed 
as usual. 

I^ever rheumatic, never had venereal disease, knows no 
cause for the attack, F. H., as far as ascertained, inconclusive. 
R. n. 

Left pupil dilated (has been using drops), one broad 
synechia ; some deposit on back of cornea ; epithelium uneven ; 
fine, grey lines in the substance of the cornea, taking generally 
a convergent direction from the periphery. Small, grey areas 
of opacity present at the meeting points of the grey lines. 
Corneal substance nowhere quite clear. Treatment: quinine 
and. atropine. 

May 19. The lines of striation in the cornea are very much 
coarser. 

May 26. The coarse lines are still present, but have faded, 
in places ; crowds of dots on the back of the cornea ; not espe- 
cially confined to one part. The synechia, up and out, remains, 



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STRIATED 0PACI1Y OF THE CORNEA. 359 

and there are other deposits of uveal pigment on the lens 
capsule. Treatment : iodide of potassium and salicylate. 

May 20. Right eye became bad on the 27th. Some syne- 
chias; striated opacity of the cornea. Treatment : hyd. c. cret. 

June 2. Coarse striated opacity is now general in right 
eye, in broad, white bands, as much as 1 mm. wide ; pupil 
dilated. 

June 16. Both pupils dilated, except for the broad synechia 
in the left ; a great deal of very coarse striated opacity in the 
right, not radiating, but running at various angles. 

July 5. The striated opacity, as such, has disappeared. 
Some grey spots are still present where trie lines were. There 
is a mass of exudation at the lower part of the anterior 
chamber of the left eye. 

August 25. Has been away at the sea- side. Had no treat- 
ment for a month. His vision and general condition are much 
worse. Right eye has many fresh posterior synechia?. In the left 
eye there is more exudation on the back of the cornea ; there are 
many broad, fleshy-looking synechias, and the mass at the angle 
of the a.c. is more prominent. Treatment : codrliver oil. 

September 15. Pupils have partly dilated again. Has been 
using scopolamine. The eyes are certainly better. He has had 
less pain, and there is less congestion. R, 6/24 + 1 D. = 6/12. 

L. 6/36, not improved. 

Urine 1012 ; acid • no albumin ; no sugar, 

October 27, In both eyes numerous broad adhesions, with 
abundant keratitis punctata, 

Left eye, Scattered, round, wliite intracorneal deposits; 
much larger than the K. P. dots, and consistent with tubercle. 

Right eye. Some deposits in lower part of angle of a,c. 

January, 1895, Quiet ; no sign of irritation • deposits in 
cornea gone ; in a.c. much less. Has been at work again, 

February 13, 1895. Fresh attack in right eye, Admitted 
St, Thomas' Hospital. 

March 20. Iridectomy upwards in each eye, 

June 29. ~No pain of any kind since operation. Both eyes 
quiet. Right eye. Much lymph on capsule in pupil ; clearer 
in iridectomy gap. 

Left eye. Less lymph in pupil than right eye. T. normal. 
Has resumed woik as coppersmith; is much more robust 



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360 STRIATED OPACITY OF THE CORNEA. 

looking than at any time since his attendance began. Healthy 
colour, plump cheeks. He says that this is his normal appear-, 
ance, which he has not had since the beginning of the attack. 

I wish to express my thanks to Messrs. Nettleship, Gunn, 
and Silcock for permission to make use of: their cases. 



Fig. 1. — Section of the cornea of Case I, showing folds of Descemet's mem- 
brane and spaces in the substance of the cornea. 

Fig. 2.— Appearance of cornea in Case I. Oblique wound with lines of 
opacity extending upwards and downwards from it. 

Fig-. 3. — Double contoured lines as seen in Case VIII. 

Fig-. 4. — Appearance of cornea in Case V. Wound of lower and inner part 
of cornea with striated opacity some distance away from it. 

Fig. 5. — Striated opacity occurring as the first manifestation of syphilitic 
iritis in Case XV. 

Fig. 6— Vertical striated lines in Case XVI wiih keratitis centralis 
annularis. 



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3(31 



TOPOGRAPHY OF THE EMMETROPIC FUNDUS. 
By Andrew Hallidie, F.R.C.S. 

The mapping out of the fundus on the outer surface of 
the eye is a subject which has been fully treated by 
several writers, notably by Donders, Cohn, A. Graefe, and 
Hirschberg. Its bearing on the operation for foreign 
body and cysticercus has an importance similar to that 
which cerebral topography has on the surgery of the 
brain. 

Although, as will be shown later, only two sets of 
measurements have been given for the normal emme- 
tropic eye, yet these, when compared with one another, 
show a decided want of agreement. It is proposed hereto 
discuss the cause of this discrepancy, and to compare the 
two sets of measurements with a third set, which will be 
obtained from a consideration of the course of oblique 
rays through the media of Helmholtz's schematic eye. 

It will be convenient to consider first the methods of 
examining the affected eye, in order to determine the 
position of the foreign body in its fundus, and afterwards 
the construction of tables for marking the position of any 
point of the fundus on the outer surface of the eye. 

Methods of Examining the affected Eye. 

Since the fundus of an emmetropic eye is nearly a 
.focal surface, any bundle of parallel rays which fall on 
the cornea will, after refraotion through the media of the 
eye, come to a focus, or nearly to a focus, at a point of 
the fundus, which point will lie in the same principal 
meridian of the eye as does the axis of the external 
bundle of parallel rays. 

In Fig. 1 Q'Q R'R is a bundle of parallel rays which, 
after refraction, meet at point P of the fundus, SX is the 
optic axis, and BB the base of the cornea. 



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362 TOPOGRAPHY OF THE EMMETROPIC FUNDUS. 

The inclination to the optic axis of any of the parallel 
rays will be called 6 (QLS, Fig. 1), and the inclination to 
the horizontal of the meridian in which they lie will be 
called X. 




Now it is evident that if the values of \ and are known, 
the position of the point P on the fundus is fully deter- 
mined. In point of fact, the determination of these 
angles is the only method we have of fixing the position 
of a point on the fundus. 

The Chart Method. 

If a small foreign body be embedded in the fundus, 
the function of the fundus at that point will be destroyed ; 
and a chart of the field of the affected eye will show a . 
scotoma, whose position on the chart will give at once 
the values of X and 0, corresponding to that point of the 
fundus, This method of determining the position of a 
foieign body is the one recommended by Cohn ; but it is 
open to the objection that the scotoma may be, and 
frequently is, much larger than that which should 
correspond to the actual area occupied by the foreign 
body. , 



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TOPOGRAPHY OF THE EMMETROPIC FUNDUS. 363 



The Ophthalmoscope Method, 

In Fig. 1 Q'Q R'R are parallel rays, which, after 
refraction, meet at P. It is a well-known law that a ray 
will take the same course through a succession of media, 
whether it be travelling forwards- or backwards. Hence 
it follows that if the point P be illuminated, the rays from 
it will, after emergence from the eye, form a parallel 
bundle QQ' RR'. An observer provided with an ophthal- 
moscope will then only be able to see the point P if his 
eye lie in the course of the rays QQ/ RR'. The relative 
position of the observer's eye to the optic axis of the eye 
examined will then give the same values of X and 6 as 
would have been found by the chart method. A. Graefe 
has described an apparatus called by him the localisation 
ophthalmoscope, by which this method of determining- the 
position of a foreign body maybe used. A perimeter has 
a concave mirror fixed just above the zero point; a 
convex lens is placed in front of this mirror so that an 
observer looking through the centre of the mirror will see 
an inverted image of the fundus of the observed eye. 

The observed eye is directed towards a fixation point, 
which can be moved round the arc of the perimeter. 

The fixation point and the arc of the perimeter are 
then so adjusted that the observer can see the foreign 
body ; and when this is the case it is evident that the 
inclination to the horizontal of the arc of the perimeter 
will give the value of A, and the position of the fixation 
point on the arc of the perimeter will give the value 
of 8. 

It will then be seen that for a given point on the 
fundus the same values of X and 6 will be obtained 
whether the eye be examined by the chart method or by 
the ophthalmoscope method. 

Professor Hirschberg, in a paper published in the 
Centralblatt (Nov., 1391, p. 321), obtains a result which 
is inconsistent with this. He finds that a point on the 



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364 TOPOGRAPHY OF THE EMMETROPIC FUNDUS. 

equator of the eye corresponds to a value of 9 66° by 
the chart method and 80° by the ophthalmoscope method. 
But it will be shown later that the table of measurements 
from which the latter angle (80°) is deduced is an inac- 
curate one, and that if it be replaced by a more accurate 
table the two angles will come into practical agreement. 

Influence of the Angle 7. 

It has been assumed so far that the line of fixation is 
coincident with the optic axis. But on an average the 
line of fixation lies 5° to the inner side of the optic axis, 
that is, the angle between them, generally known as the 
angle 7, has an average value of 5°. The values of X and 
9 we have previously obtained are referred to the line 
of fixation and not to the optic axis. 

The corrected values of X arid 9 may be easily ob- 
tained in the following manner : Mark on the chart the 
position of the point referred to the line of fixation ; from 
this point draw towards the inner side of the field a hori- 
zontal line whose length would correspond to 5° (or what- 
ever the value of 7 may be for the eye examined) according 
to the scale of the chart. From the position of the extremity 
of this line on the chart the corrected values of X and 9 
may be at once read off. 

The Construction of Tables. 

Having thus determined the values of X and 9, it is 
necessary to find from these values the position of the 
point P on the sclerotic. 

The meridian of the eye in which P lies is easily 
marked out from the value found for X. It remains to 
determine the position of P on this meridian from the 
value found for 9. 

The position of a point is found practically on the 
living eye by measuring its distance behind the margin of 
the cornea by means of a pair of calipers. This mode of 



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TOPOGRAPHY OF THE EMMETROPIC FUNDUS. 365 

measurement gives the length not of the arc of the 
meridian, but of the chord of this arc, i.e., of the straight 
line BP (Fig. 1). This length will be denoted by the 
letter d. 

If, therefore, a table be constructed giving the value 
of d corresponding to values of 6 0°, 10°, 20°, 30°, .... 
90°, it will be easy to find approximately the value of d 
for any intermediate value of 6* 

Bonders' Method. 

Such a table was published by Donders in the Arch, 
f. Oph., xxiii, 2., p. 255. He obtained it by measuring with 
calipers the distance behind the corneal margin of the 
image of a flame as seen shining through the sclerotic. 
The eye in which the measurements were made was 
emmetropic and greatly proptosed, so that the image of 
the flame could be seen much further back than would 
be possible in a normal eye. 

His results, which extend between the values of 6 40° 
and 90°, are given in the following table : — 

Table I. 



e 40°. 50°. 60°. 70°. 80°. 90°. 

d 17 155 13-4 11-4 9'5 8 

Graefes Methods. 

In the Arch. f. Oph., xxviii, 1, p. 187. A. Graefe 
gives two methods of constructing a table. 

In the first method the breadth of the optic disc is 
taken as the unit of measurement (=1*4 mm.) ; the eye 
is represented by a circle of 24 mm. diameter; and the 
width of the base of the cornea is taken as 11*6 mm. 

The value of d can -be measured in such a figure for 
each disc's breadth on either side of the disc. 

Graefe's second method is also a graphic one, and is 
founded on a well known property of nodal points. 
Every system of spherical refracting surfaces has two 



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306 TOPOGRAPHY OF THE EMMETROPIC FUNDUS. 

nodal points, and a ray which, in the first medium, passes 
through the first nodal point, will in the last medium pass 
through the last nodal point, and have a direction parallel 
to its original direction. This property only holds for 
rays which lie near the axis of the system, and if it be 
assumed to hold for very oblique rays, the error will be 
appreciable, though not very great. The nodal points of 
the eye lie very close together, being separated by a dis- 
tance of 0*36 ram., so that they may, for all practical pur- 
poses, be considered as one point ; any ray passing 
through this point will remain un deflected. 

The position of the image of a distant point on the 
fundus is taken to be the point where a line through it and 
the nodal point meets the fundus, for all the rays from 
the distant point meet at the same point in the fundus. 

Graefe represents the eye by a circle of 24 mm. 
diameter, as before, and places the nodal point 15 mm. in 
front of the posterior pole of the eye. Lines are drawn 
through the nodal point, making angles of 10° 20° .... 90° 
with the optic axis, and the distances of the point where 
these meet the circle from the edge of the cornea are 
measured. Hirschberg, by using this method, obtains the 
results given in Table II. 



Table II. 






20°. 40°. 


60*. 


80°. 


20 18-5 


165 


122 



A comparison of this table with Table I shows a 
marked want of agreement, and this want of agreement 
is due to the fact that the property of nodal points given 
above holds only for small values of 0. Landolt and 
Nuel found that in the case of rabbits' eyes, the larger 
the value of 6 the further forward is the point where the 
direction of the rays in the vitreous will meet the optic 
axis, or, as they state it, the nodal point for oblique rays 
is further forward than the nodal point for direct rays. 
(Arch. f. Oph., xix, 3, p. 30 L) 



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TOPOGRAPHY OF THE EMMETROPIC FUNDUS. 367 



A nother Method. 

The position of images of external objects on the. 
fundus cannot then be accurately determined by making 
use of the nodal points of the eye. True accuracy can 
only be assessed by tracing the course of one ray for each 
value of 9. Since the fundus is practically a focal surface, 
the point where one ray from a distant point meets it is 
the point where all the rays from that point meet it, and 
is therefore the position of the image of that distant 
point. 

If, then, in a diagram representing the average shape 
of an emmetropic eye, the course of one ray be drawn for 

each value of 6 0°, 10°, 20 D 90°, an accurate table may 

be constructed by direct measurement in the diagram of 
the corresponding values of d. 

In using this method we have taken HelmholtzV 
schematic eye as representing the average shape of the 
emmetropic eye, and enlarged it to 10 times the natural 
size. The diagram on which the measurements were 
made is represented on a smaller scale in Fig. 2. The 
results so obtained are given in Table VII, which, it will 
be seen, agrees closely with Donders table ; the difference 




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368 TOPOGRAPHY OF THE EMMETROPIC FUNDUS. 

between the corresponding values of d in the two tables 
is in no case greater than half a millimetre. 

■The determination of the course of a ray passing 
obliquely through the crystalline lens is rendered extremely 
difficult, from the fact that the lens is not homogeneous. 
The lens is formed of a series of homogeneous layers, 
arranged concentrically with its surfaces ; the refractive 
index of these layers increases from 1-3880 at the cortex 
to 1*4107 at the nucleus. 

Matthiessen has proved (Pfluger's Arch., xix, p. 543) 
that for rays which pass through the nucleus, the crys- 
talline lens has the same action a>s would a homogeneous 
lens of the same external form, and of refractive index 
1*4371. This last number he has named the total index 
of the lens. 

Rasmus and Warner subsequently (Pfluger's Arch., xx, 
p. 264) investigated the course of a succession of oblique 
rays, which all pass through the nucleus of the lens, and for 
which, consequently, the lens maybe considered as homo- 
geneous, and of refractive index 1*4371. They used the 
constants calculated by Helmholtz for his schematic eye. 

Radius of curvature of anterior surface of lens . . 10 mm. 

>, „ posterior „ ' .. 6 „ 

Distance of anterior surface of lens from ainterior 

surface of cornea /...... 3"6 ,, 

Distance of posterior surface of lens from ^nterior 

surface of cornea 1 7*2 „ 

Index of refraction of aqueous and vitreo/us . ♦ . . 1*3365 

lens ., .( 1-4371 

The section of the outer surface of the cornea they 
took as being represented by an ellips^, whose major axis 
(practically coincident with the axis! of the eye) was 
22*018 mm. long, and minor axis 18*54/4 mm. long. From 
this it follows by a simple calculation, that the anterior 
focus of the ellipse (F, Fig.- 1) is 5/'074 mm. behind the 
apex of the cornea. Now it will l^e found that any ray 
which, in its course through the aqueous, is directed 



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TOPOGRAPHY OF THE EMMETROPIC FUNDUS. 369 

towards F, will, in its course through the lens, pass through 
the nucleus of the lens. For all such rays, then, the lens 
may be considered as homogeneous, and of refractive 
index 1-4371. 

In Fig. 1, the ray R'R, after refraction at the cornea, 
takes a course RF, and after refraction at the post surface 
of the lens, a course TP. 

Rasmus and Wauer have investigated the course of a 
series of such rays, for which the angle RFS has the values 

0°, 10°, 20° 90°. Representing the inclination of RR' 

to the axis by 0, the angle RFS by <p, and the angle PTX 
by y{r, the values found by them are given in Table III. 









Table III. 








0- 




e. 




+- 




FT. 




0° 














0-1981 




10 


11° 


9' 


41" 


9° 5' 


24" 


0;202 




20 


22 


21 


32 


19 43 


7 


0-213 




30 


33 


33 


4 


29 32 


18 


0-235 




40 


44 


45 


41 


39 18 


25 


0-269 


/' 


50 


55 


59 


36 


49 


15 


0-320 


I 


60 


67 


15 


5 


58 37 


22 


0396 


\ 


70 


78 


30 


40 


68 12 


8 


0505 


\ 


80 


89 


45 


52 


77 52 


22 


0-657 


90 


100 


58 


50 


87 49 


34 


0-845 





From this table it is necessary, lor the purpose we have 
in view, to calculate the constants of rays for which 6 has 
the values 0°, 10°, 20° 90° ; these are given in Table IV, 





G 


Fable 


IV. 




e. 


" \ 


+-■ 




FT. 





~\ 







0-1981 


10° 


\ 8° 


50' 


28" 


0-2016 


20 


! 17 


38 


36 


0-2107 


30 


\ 26 


25 


22 


0-2280 


40 


\ 35 


9 


28 


0-2546 


50 


'v43 
152 


49 


47 


0-2928 


60 


25 


39 


0-3471 


70 


69 


57 


40 


0-1226 


80 


28 


54 


0-5251 


90 


78\ 


4 


55 


0-6610 



\ 



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370 TOPOGRAPHY OF THE EMMETROPIC FUNDUS. 

The constants given in this table are sufficient to' 
enable us to draw the course of any of these rays in the 
vitreous of the schematic eye. 

To find the value of </> for the last ray which passes 
through the nucleus of the lens, the angle BB'S (Fig. I) 
should be measured in Helmholtz's schematic eye ; its 
value is 64° 30'. The corresponding value of 6 is found, 
from Table III, to be 72° 30'* And no ray inclined a 
greater angle than 72° 30' to the axis of the eye can pass 
through the nucleus of the lens. 

Hence Table IV cannot be used for drawing the course 
in the vitreous of rays for which 6 = 80° or 90°. 

Mathiessen, however, has, in Arch. f. Oph., xxv, 4, 
p. 257, found the constants of a series of rays which in 
their course through the aqueous are directed towards the 
apex of the anterior surface of the lens (S' ? Fig. 1). In 
Fig. 1 Q'Q is such a ray; its course outside the eye would, 
if prolonged, meet the axis in L, and its course in the 
vitreous would, if prolonged backwards, meet the axis 
inT'. 

Representing the angle Q'LS by #, PT'X by yjr, and 
QFS (the polar angle of the point Q on the corneal 
ellipse) by </>', his results are given in Table V 

Table V. j 

0'. 0. ty. ' FT'. 

0° 0- .' 1-3666 

10 16° 32' 50" 13° 23' 45" < 13650 

20 32 35 30 26 14 20 j 1*3622 

30 47 38 40 38 1 50/ 1*3585 

40 61 53 50 48 47 10/ 13553 

50 75 10 58 18 30f 1-3589 

60 87 11 40 66 45 12 ( 1*3721 

Proceeding as before, we may calculate the constants 
of rays corresponding to values of f C , 10°, 20°. . , . 90° 
These are given in Table VI. 



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TOPOGRAPHY OF THE EMMETROPIC FUNDUS. 371 







Table VI. 




e. 




+'. 




FT'. 


0° 









1-3666 


10 


8° 


5' 


44" 


1-3656 


20 


16 


9 


35 


1-3644 


30 


24 


9 


52 


1-3627 


40 


32 


2 


32 


1-3604 


50 


39 


48 


29 


1-3580 


60 


47 


21 


16 


1-3557 


70 


54 


40 


24 


1-3575 


80 


61 


46 


11 


1-3643 


90 


68 


41 


48 


1-3751 



The value of 6 for the last ray which can pass the S' 
is 94°. 

In the construction of Fig. 2, it will be found con- 
venient to draw the path in the vitreous of rays corre- 
sponding to values of 8 0° — 50° from the constants given 
in Table IV, and those corresponding to values of 60° — ^0° 
from the constants given in Table VI. Thus the former 
rays are, in their course through the aqueous, directed 
towards F, the latter towards S'. 

The values of cl are measured from the point where each 
ray meets the outer surface of the sclerotic to the margin 
of the transparent part of the cornea. 

These values are given in Table VII. 



Table VII. 










0°. 10°. 20°. 30°. 40°. 50°. 


60°. 


70°. 


80°. 


90°. 


21-6 20-6 19-6 18-4 17 15'4 


13-75 


11-9 


101 


8-2 



The equator of the schematic eye is found by drawing 
two lines parallel to the optic axis and touching the outer 
surface of the sclerotic. Its distance from the margin of 
the cornea will be found from Fig. 2 to be 11*9 mm., and 
to correspond to a value of 6 == 70°, 

Now, from a consideration of Fig. 2, it will be seen 
that we have found the positions on the outer surface of 
the sclerotic corresponding to the images on the retina by 
VOL. XIV. 2 B 



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372 TOPOGRAPHY OF THE EMMETROPIC FUNDUS. 

the course of the rays through the thickness of the scle- 
rotic. This gives measurements for the schematic eye 
"which are strictly comparable to Donders' measurements 
on the living eye, as given in Table I. 

But it would be more. accurate to draw. lines from the 
centre of figure of the eye through the retinal images 
and to take the points where these lines meet the outer 
surface of the sclerotic as corresponding to the positions 
of the retinal images. This is what has been done in the 
lower half of Fig. 2. 

The corrected values of d, obtained in this manner, are 
given in Table VIII. 











Table VIII. 




a 


0°. 


10°. 


20°. 


30°. 40°. 50°. 


60°. 70°. 80°. 9CP. 


d.. 


21*6 


20-6 


19*5 


18-3 16'8 15-2 


13'4 11-4 9-5 7-8 



And it will be seen from examination of the lower half 
of Fig. 2 that the equator for which d = 1 1*9 mm. corre- 
sponds to a value of 9 = 67°. 

Conclusion, — The results we have obtained may be 
summed up shortly thus : — - 

The examination of the eye for the determination of 
the position of a foreign body in the fundus, whether con- 
ducted by the chart method or by the ophthalmoscope 
method, will give the same pair of angles, X and 9. Of 
these X is the inclination to the horizon of the meridian in 
which the foreign body lies ; and 9 is the inclination to the 
optic axis of rays of light which, after refraction through 
the media of the eye, would come to a focus at the posi- 
tion of the foreign body. 

The distance of the foreign body from the margin 
of the cornea can be obtained from the value of 9 by 
means of a table constructed for this purpose. 

Table I is such a table ; it has reference to the living 
eye examined by Donders, and is necessarily incomplete. 

Table VIII is such a table, constructed for the sche- 
matic eye of Helmholtz. 



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TOPOGRAPHY OF THE EMMETROPIC FUNDUS. 373 

The close agreement of Tables I and VIII is striking. 

The equator of the eye lies 11*9 mm. behind the margin 
of the cornea, and corresponds to a value of 8 = 66° or 67°. 

Tables I and VIII are constructed for emmetropic eyes. 

For myopic eyes the values of d will be somewhat 
larger, and for hypermetropic eyes somewhat smaller. 



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374 



CA.SE OF PERMANENT CENTRAL SCOTOMA CAUSED BY 
LOOKING AT THE SUN, WITH PARTIAL ATROPHY OF 
THE OPTIC NERVE. 

By E. Treacher Collins, 
Assistant Surgeon to the Hospital. 

In the Ophthalmic Review, for 1894, Dr. George 
Mackay published a series of papers on blinding of the 
retina from direct sunlight, in which he epitomised 
all the recorded cases he was able to find, and added 
descriptions of seven new cases which had come under 
his own observation. After carefully reading through 
his papers I find that the following case, which has been 
under my care at Moorfields Hospital, presents some 
unusual features which make it worthy of record. 

Sarah K,., aged 49, a sohoolmistress, one day in the early 
part of May, 1839, about 4 or 5 p.m., casually glanced at the 
sun, when she noticed that it was surrounded by a beautiful 
halo composed of rainbow coloured rings of light. This 
phenomenon was also observed by others, and was subsequently 
described and pictured in a periodical journal. She continued 
to look at the sun for five to ten minutes, only shading her eyes 
occasionally with her hand. Upon turning away she saw two 
yellow discs upon the grass before her, the right one was a 
complete circle, the left was imperfect having a notch in it 
like this c3 , The yellow colour of the discs changed to blue 
when she went into a rather shaded room and looked at a 
white table cloth, The coloured discs wore only faintly visible 
the next day, and were entirely gone by the third day. Then, 
however, there seemed to he cobwebs in front of her eyes, 
which she kept trying to brush away, In school the children's 
faces at a distance of 7 or 8 yards, appeared to have a blot on 
them. By the seventh day <( the sight of her left eye had 
gone," though she thinks she was always able to distinguish 
lio-ht from dark with it. At the end of three or four weeks 
the sight of her right eye had completely recovered. Towards 
the end of June, on looking at an object with her left eye, it 



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CASE OF PERMANENT CENTRAL SCOTOMA. 375 

appeared enveloped in a fog, and seemed to have irregular 
shaped blanks- in it, though she was able to make out its lower 
part. Since that time the sight of her left eye has only 
slightly improved. 

She states definitely that she had never noticed any defect 
in either of her eyes previous to looking at the sun. The 
discs in front of her eyes never seemed to oscillate or move, 
and straight lines looked at with her right eye never seemed 
bent. 

She was treated from the seventh day with bromide of 
potassium internally, repeated blisters over the eyebrow, and 
afterwards with dark glasses. 

On October 4, 1889, she attended at the Moorfields 
Hospital, when the following notes were made as to the condi- 
tion of her eyes : — 

Y. R. = 6/18 ; L. = fingers at 3 feet. 

Has a large central scotoma in the left which cannot be 
mapped out. Both fields for white are slightly contracted ; in 
the centre of the left white objects can only be seen with 
difficulty, red and green are quite invisible. 

Ophthalmoscopic 'Examination.- — The left disc is paler than 
the right, and is somewhat cupped. The edges of the right 
disc are blurred and there are some slight changes about the 
right macula resembling what is termed central guttate 
choroiditis. 

She attended again at Moorfields Hospital on January 15, 
1895, when I first saw her. 

The condition of her eyes was then as follows : — 

Y. R. 6/18 c — 1 = 6/Q, c + 1, J.l ; L. can count fingers only 
at 3 feet. 

The field of vision of each eye was of normal size. 

On being asked to look at a w r hite patch in the centre of 
her, left field she said that it came and went, it was impossible 
to mark out any definite scotoma* There was a well-marked 
central scotoma for red. A green patch 15 mm. square was 
not seen as green in any part of the field, but a skein of green 
wool held in the lower part was recognised as green. 

The yellow patch, 15 mm. square, she described as white in 



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376 .CASE OF PERMANENT CENTRAL SCOTOMA 

all parts of the field. Blue could be distinguish ed except in 
the centre. 

Ophthalmoscopic Examination. — Left eye. The optic disc 
is distinctly pale in colour, and the outer half markedly white. 
The retinal vessels do not appear to be diminished in size. 
The yellow spot looks normal except for one small shining 
white spot immediately below it. — Right eye. The optic disc 
and retinal vessels are normal, there are a few white dots seen 
in the macula region. 

The points of interest in .this case specially note- 
worthy, are as follows • :— -First, the great defect in vision 
which resulted from the exposure. Her statement is that 
by the seventh day the sight of her left eye had gone, 
though she thinks she was still able to see light from 
dark with it, and now seven years after she is only able 
to count fingers at three feet. With regard to the 
degree of impairment of sight, Mackay says : " the 
greatest defect (excluding Jaeger's two very exceptional 
cases, in which malignant growths appeared) has been 
recorded by Dufour, in a man who, four days after the 
exposure, had R. V. = 1/20. He had presumably enjoyed 
good vision in this eye previously, for in three weeks V. 
rose to = 1/2. Beyond that it never improved. More 
frequently the primary reduction has been to V. = 1/3 or 
1/2, or 2/3 of the normal/' 

The exposure to the sun, which in my patient, brought 
about this apparently unprecedented defect of vision, 
seems to have been a very prolonged one, for she tells 
me she continued looking at it for from 5 to 10 minutes, 
while her husband and a friend who were standing by 
her could only just glance at it. No case, so far as 1 am 
aware, has yet been recorded in which blinding by 
exposure to sunlight has been followed by atrophy of the 
optic nerve, but apparently that is what has occurred in 
this patient, She states very definitely that she had 
never noticed any defect in either of her eyes before she 
looked at the sun : she then had negative after-images, and 



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CAUSED BY LOOKING AT THE SUN, ETC. 377 

a few clays later the permanent central defect was first 
noticed in her left eye. Five months afterwards when an 
ophthalmoscopic examination was made, palor of the 
optic disc was noted 5 now seven years after the exposure 
there is certainly atrophy, the defect of vision remains 
much about the same, and she has developed no symp- 
toms which might indicate some other cause for the 
nerve change. The recent experiments by C. H. Usher 
and Geo. Dean, communicated to the Ophthalmological 
Society,* help us, 1 think, to understand the way in which 
a partial atrophy of the optic nerve may ensue from a 
lesion such as that likely to be produced from a prolonged 
exposure to the sun. These observers made wounds in 
the retinae of animal's eyes with a Graefe's knife, and 
with the galvano-cautery ; and then afterwards by 
staining sections of the nerves by Marchi's method, were 
able to discover and trace tracts of degeneration in them. 
They found that the degeneration always corresponded 
to the part of the retina that had been wounded, and that 
in a monkey's eye when the lesion was made between 
the optic disc and yellow spot the area of degeneration 
lay, as might have been expected, in the outer part of the 
nerve anteriorly. 

Now in my patient, if we imagine the exposure to the 
sun to have caused the destruction of some of the retinal 
elements in the macula region, the effects would be 
quite comparable to those produced by Usher and Dean 
by wounds of the retina, and as a result, atrophy of nerve 
fibres supplying the macula region expected. Though 
there was a general palor of the optic disc in mj patient, 
the outer part of it was decidedly the whitest. 

In this case the defect of vision for colours though most 
marked in the central region was not confined to it. 
Thus for red and blue there was only a central defect, 
while a patch of green, 13 mm. square, was not recognised 

* Transactions, vol. xvi, p. 248. 



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378 CASE OF PERMANENT CENTRAL SCOTOMA. 

as green in any part of the field and a patch of yellow 
of the same size was everywhere described as white. 

Mackay, from his own observations, arrived at the con- 
clusion that the defect for colours is usually more exten- 
sive and more profound than that for white, and he refers 
to the case of a distinguished English physicist who 
attributed a difficulty in his power of perceiving yellow 
to the exposure of his eyes to the sun during an eclipse in 
his youth. 



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379 



ON THE PATHOLOGICAL EXAMINATION OF THE EYEBALL. 

By C. Devereux Marshall, Curator. 

As the methods used in the pathological examination of 
the eyeball differ somewhat in detail from those in general 
use, and as the subject receives somewhat scant treatment 
in many of the text-books on pathological histology, I 
think it may be useful to many persons to give in detail 
the usual methods of procedure when an eye requires 
examining after its removal. 

I shall presume that the essentials of practical histology 
are well known to all, and if they are not I could not do 
better than refer them to one or other of the excellent 
books already published.* 

As s:>on as an eye is removed it should be carefully 
examined with the naked eye, and all the points of interest 
noted in their regular order. This is most essential, as it 
frequently happens that certain tilings are observed in the 
fresh eye which are much more difficult to make out after 
it has been hardened. 

On the sclerotic must be noticed the state of the 
vessels. If there has been severe inflammation, and 
especially if it has continued for a long time, we fre- 
quently see that the tissues lying close to the eye have 
become thickened and infiltrated, and consequently a 
certain amount of fat adheres to the globe; in very 
severe cases the large lymph, space within the capsule of 
Tenon may be entirely obliterated, and the tissues so 
adherent that the sclerotic really has to be dissected 
away from the orbital fat. 

If the observer does not know whether he has a right 
or a left eye to examine, he can easily determine this by 
observing the position of the tendons of the oblique muscles. 

The tendon of the inferior is far more fleshy, and 

# Schafer's Essentials of Histology; Klein, Practical Histology. 



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380 ON THE PATHOLOGICAL EXAMINATION 

attached nearer the optic nerve than that of the superior 
oblique, and they are both inserted towards the outer side 
of the globe. If now the eye be held with the tendon of 
the superior rectus (which is close to and just above that 
of the superior oblique) directly upwards, and the cornea 
forwards^ the side on which the oblique tendons are situated 
will correspond to the side to which the eye belongs. 

The next thing to do is to examine the eye by means of 
an artificial light, in an otherwise darkened room. A small 
electric hand lamp, set in a metal case, with a condenser 
in front of it, and a reflector behind it, is extremely useful. 

The light should be allowed to shine into the globe 
through all parts of the sclerotic and cornea in turn, and 
when looking on the side opposite to the lamp it is often 
possible to see by the non-penetration of the light if a 
solid growth be present. Another very good way is to 
hold the light behind the eye, and to look through the 
pupil; on rotating the globe in various directions such 
things as a detached retina or a small tumour are some- 
times discovered. 

As soon as anything of interest is seen its position 
should be accurately marked out with a pen and ink on 
the sclerotic, so that if the lens or cornea become subse- 
quently opaque, it is easy to recognise the affected area. 

All the areolar tissue and tendons should now be care- 
fully cut away by means of a pair of scissors and forceps. 

As soon as this is done the eye is put in some form of 
hardening fluid. 

Hardening. — Of the various fluids in general use for 
this process there are two which are much better than any 
other, they are (1) Formol, (2) Miiller's fluid. 

Formol. — This is far and away the most convenient re- 
agent to use, and it was first introduced for this purpose 
by Professor Leber about two years ago. It is supplied 
under two names, viz., formol and formaline. It consists 
of a saturated (40 per cent.) solution of formic aldehyde in 
water, but it must not be used in its full strength, a JO per 



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OF THE EYEBALL. 381 

cent, solution is very good, as it hardens quickly and 
thoroughly, weaker solutions may also be used, though, 
of course, they take longer. 

If a 10 per cent, solution be used, the eye is ready in 
24 hours to allow of its being frozen and bisected. 
There is no harm, however, in leaving it in for a much 
longer time than this, as it does not overharden. A full 
description of this substance will be found in a paper pre- 
viously published by the author.* 

It is admirably adapted for transparent tissues like 
the cornea, as it neither stains nor renders them opaque. 
Should this not be obtainable, Miiller's fluid is the next 
best thing to use, and it is made as follows : — - 

Bichromate of potash 2*5 parts. 

Sulphate of soda 1 „ 

Water . 100 „ 

This is used in its full strength, and the eyeball is 
placed hi it as soon as it is removed. It is advisable to use 
a rather large bulk of fluid, and to keep the bottle in the 
dark. It however possesses two marked disadvantages : 
(1) It takes at least three weeks before the globe is 
hardened, (2) it colours the sclerotic and cornea brown, 
and a considerable time is taken up in bleaching it before 
it can be put up as a museum specimen. 

Almost any other hardening reagent may be used, e.g^ 
alcohol, chromic acid, perchloride of mercury* picric acid> 
&c.,but they are all far inferior to formol or Miiller's fluid. 
Most of them render the transparent parts of the eye 
opaque, and alcohol has the disadvantage of preventing 
the eye from freezing unless it has been soaked for 24 
hours or more in water after hardening. 

Freezing and Gutting. — In whatever way the eyeball is 
hardened it is far safer to freeze it before cutting it open. 
None of the hardening reagents make the vitreous solid, 
and unless an excessively sharp knife is used there is 

* Trans, of Ophth. Society, 1895. 



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382 ON THE PATHOLOGICAL EXAMINATION 

always a danger of displacing the lens if an anteropos- 
terior section be made, this is especially likely to take place, 
if it has been loosened or partially dislocated by injury or 
disease. 

The best and cheapest way of freezing eyes is by 
means of an ordinary freezing mixture made as follows : — 
Chop up some ice into small lumps, and place it upon a 
plate, add about one quarter its bulk of salt, and thoroughly 
mix. Then take an ordinary cylindrical tin, the bottom of 
which has already been perforated with several holes, and 
in it place the eyes, which may be done up in gutta-percha 
tissue to prevent injury, taking great care that they are 
well surrounded with the ice and salt. They should be 
left in this for at least half an hour, and if more intense 
cold is required it maybe obtained by adding some nitrate 
of potash to the freezing mixture. 

After the freezing is complete the eyes may be opened, 
either in an antero-posterior or else a transverse direction. 
It is well, however, to have the line of section marked 
before they are frozen, as it is so much more difficult to 
recognise the position of things afterwards. As soon as 
this is done, the bisected eye is placed in water to thaw. 
The best instrument for cutting an eye is an ordinary brain 
knife or even a table knife. A razor is by no means suit- 
able, owing, first of all, to the extreme thinness of the 
blade near the edge, which allows it to get notched very 
readily; and, secondly, owing to its back being far too 
thick to pass smoothly through the partially divided globe. 

After thawing it can be examined macroscopically. If 
the eye contain anything cf interest \t is usual to keep one 
half for further examination by means of the microscope, 
while the other half is mounted as a museum specimen. 
We will consider these two separately. 

(1) Method of Mounting Specimens for the Museum, — 
As soon as all the chief points are noted, the half which is 
intended to be mounted may be again put into formol 
(10 per cent.) for 24 hours, especially if it has been opened 



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OF THE EYEBALL. 383 

within a clay or two of its removal ; this will ensure its 
being properly hardened, if it has been kept some days in 
formol before opening this is unnecessary, and it may be 
at once placed in a mixture of glycerine and water in the 
proportion of 1 part of the former to 2 parts of the 
'latter. It should be left here for at least two or three 
days, and after that time it is transferred to a solution of 
equal parts of glycerine and water, and left to soak for a 
further period of a few days. It is then ready to mount. 
In order to do this the following things are required: — 

1. Glass pots, 2 inches in diameter and f inch deep, 

obtainable at Powell and Sons, Tudor Street, E.G. 

2. Small opal dishes, 1|- inches in diameter. 

3. A bottle of glycerine jelly (the directions for its 

manufacture are given below, p. 386). 

4. Teezing needles. 

5. Pins and thin cards. 

6. Canada balsam. 

7. A small hand mirror. 

8. A glass tube. 

9. Some strong formol. 

The glass pots must be prepared by being thoroughly 
cleaned, especially on the inside, as every mark here will 
show after the preparation is made. 

A bottle of jelly is taken and stood in hot water until 
it is melted. A sufficient quantity is then poured out into 
the glass pot, so as to about half fill it. Should there be a 
lot of small air-bubbles in the jelly these can be easily 
sucked up in the glass tube and removed ; any larger 
bubbles can be dispersed by pricking them with a hot 
needle. 

Having thus got the melted jelly free from foreign 
bodies and air- bubbles, the specimen which is to be 
mounted is taken out of the glycerine solution, and placed 
in the jelly with the concave surface looking upwards ; 
there should be enough fluid present to completely cover 



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384 ON THE PATHOLOGICAL EXAMINATION 

the specimen. In this way all air is removed from the 
interior of the eye. The next thing to do is to turn it 
upside down, that is, with the flat cut surface against 
the bottom of the pot and the convex surface looking 
upwards. This manoeuvre requires a little practice in 
order -to do it without admitting air into the vitreous 
chamber. The best way of accomplishing it is to take a 
teezing needle in each hand. The one in the left hand is 
placed against the outside of the sclerotic, midway between 
the cornea and optic nerve and near the cut surface. The 
other is placed in a similar position on the right side. 
Now by pressing the two needles together the eye is 
made to assume an elliptical shape ; then by a combined 
action of the two needles the specimen is rapidly rotated 
on its longitudinal axis until the concave side looks down- 
wards towards the table. 

As soon as this is done, the glass pot is raised and held 
over the small mirror ; it is then easy to see whether any 
air bubbles have got into the interior of the globe, or 
whether any part of the eye, e.g., the lens, has become dis- 
placed. If anything of the sort has happened, the eye 
must be at once turned over again, when the defect can 
be remedied. As soon as this is done, it is again inverted 
and examined, and if found to be satisfactory, it must be 
secured in its proper position while the jelly sets. A strip 
of card about f inch wide and 3 inches long is taken, 
and through the middle of this a pin is thrust. It is 
then laid across the bottom of the pot resting on its 
two sides and with the point of the pin directed down- 
wards and. projecting sufficiently far so as to rest gently 
upon the convex surface of the selerotic ; this will be 
sufficient to prevent the specimen from floating or shifting 
while the jelly is still in a fluid state. As soon as it is 
sufficiently firm the card is removed, and any unevenness 
on the surface of the jelly can readily be got rid of by 
holding a hot flat iron near the surface, or by gently 
touching any irregularity on the surface with an ordinary 



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OF THE ETEBALL. 385 

section lifter made hot in a spirit lamp. After it has be- 
come quite firm, an opal glass disc is fixed on with 
Canada balsam, or still better, with cement or glue. 

A specimen thus put up is ready to be placed in a 
wooden stand in the museum, and should undergo no 
further alteration. 

This method has one disadvantage which, though it need 
hardly be taken into consideration in this country, yet it is 
of great importance to workers in hot climates. I refer to 
the comparatively low melting point of the glycerine jelly. 

This can, fortunately, be overcome in a very simple 
manner by the aid of that most useful substance — formol. 
If formol be added to a solution of gelatine, the mixture 
remains to all appearances exactly the same, but it has 
undergone a curious change, by means of which it is im- 
possible to render it again fluid.*" 

Now, if we add a few drops of formol to some liquefied 
glycerine jelly, and allow it to cool, it will be found that, 
after 24 or 36 hours, no amount of heat will render it 
again fluid. It can be heated over a Bunsen flame, or 
water may be boiled on its surface without producing any 
liquefaction. 

In order to render specimens proof against heat, the 
following method is adopted : — 

Pour a small quantity of formol into a test-tube, and 
to this add a sufficient quantity of glycerine jelly in the 
proportion of about 3 minims of the former to each drachm 
of the latter, and mix them thoroughly together. Then 
proceed to mount the specimen in the manner already 
described. As, however, a large number of air bubbles 
get mixed with the jelly when the tube is shaken this 
may be dispensed with, and the formol simply be put first 
into the glass pot, and the jelly then poured on top of it ; 
in this way the mass gets well impregnated with the 
formol. 

* A full account of the behaviour of formol on gelatine is given in a 
paper read before the Ophthalmological Society of Great Britain in October 
1896. 



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386 ON THE PATHOLOGICAL EXAMINATION 

We thus have a preparation permanently put up in 
jelly which is incapable of being melted by even a tropi- 
cal temperature. The jelly is not rendered in the least 
opaque by formol, but rather the reverse, it makes it more 
brilliant. 

In order to magnify the specimen, a plano-convex lens 
may be stuck on to the bottom of the pot before the speci- 
men is put in it. This method was introduced by Mr. 
Treacher Collins, and certainly many preparations look 
much better as the result, but it has the disadvantage of 
giving a somewhat distorted view of the object, and the 
reflection off the surface of the lens is confusing. The 
following method is used in order to fix it : — After having 
thoroughly cleaned the pot, a plano-convex lens is taken, 
and its flat surface is smeared well over with Canada balsam 
similar to that used for mounting microscopic sections. 
This is then placed in accurate position on the bottom of 
the pot, and the two are put in an oven to bake. It is 
absolutely essential that no air bubbles be allowed to 
enter between the two surfaces of glass, and great care 
must be taken to prevent the lens from slipping and be- 
coming adherent in a wrong position. This is often a 
very troublesome procedure, and it frequently happens 
that many trials are necessary in order to get a successful 
result. If all has gone well, it should, after cooling, be 
so adherent that only the greatest pressure is able to 
move it, and it is often impossible to shift it. There is 
no fear of the balsam shrinking when once set, though 
it frequently gets full of air bubbles during the pro- 
cess of baking. When this happens, the lens must be 
removed, and the whole thing cleaned and the process 
restarted. 

Glycerine jelly is made as follows : — Cut up 30 grams 
of the best French gelatine (Coignet's gold label gelatine 
is the best), and on it pour 240 c.c. of a cold saturated 
"solution of boracic acid (made with boiling distilled water). 
Add 80 c.c. of glycerine and the white and shell of one 



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OF THE EYEBALL. 387 

egg. Mix well, heat in a water bath, and when the albu- 
min is partially precipitated, add 1 c.c. of glacial acetic 
acid. Boil thoroughly for some minutes, and then filter 
twice through flannel, and once or twice through filter 
paper in a hot water funnel. In order to aid the filtering, 
this may be done before adding the glycerine, though 
usually it goes through without difficulty. 

Microscopic Examination of the Eye. — The eye can be 
prepared for microscopic examination by any of the ordi- 
nary methods, but, inasmuch as it is most important to 
keep all the parts in their proper position, a few precau- 
tions must be observed. 

Of the three chief processes which are in common use, 
viz. : freezing and cutting in gum, embedding in paraffin-, 
and embedding in celloidin, nothing comes up to the latter 
as far as eyes are concerned, and for this method the 
following advantages can be claimed s— 

(1) It holds all the parts well together, so that there 

is no fear of getting them disturbed after cutting. 

(2) It is unnecessary to soak the celloidin out of the 

section, as it is quite transparent, and in no way 
interferes with the subsequent examination. 

(3) The sections can be manipulated without injuring 

them, and they hardly ever tend to curl up. 

(4) They can be kept an indefinite time in spirit after 

having been cut. 

There is, perhaps, one slight disadvantage in this 
method, and it is, that owing to the block being somewhat 
springy, it is not possible to cut quite such thin sections 
as can be done after embedding in paraffin, but, inasmuch 
as it is seldom necessary to examine sections of a whole 
eye with very high powers of the microscope, this hardly 
matters, as it is always possible to cut a small piece of an 
eye in paraffin, or else to freeze it With due care, how- 
ever, celloidin sections can be cut thin enough for- all 
practical purposes* 

vol. xiv. 2 o 



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388 ON THE PATHOLOGICAL EXAMINATION 

Embedding in Celloidin. — The portion of the eye 
which is to be examined microscopically is taken, after 
having been thawed in water, and placed in methylated 
spirit, which mnst be pure and not mixed with petroleum, 
as is the case with that which is sold in this country for 
burning purposes. If this cannot be obtained, rectified 
spirit must be used. After remaining in this for 24 hours it 
is placed in absolute alcohol for two days, and then in thin 
celloidin for 24 hours, and finally into thick celloidin for a 
similar period of time. 

If time be no object better results are obtained by 
dehydrating very gradually in 30 per cent, alcohol, and 
passing the specimen from day to day into a stronger and 
stronger solution, until they get into absolute alcohol. 
After this they are soaked in equal parts of absolute 
alcohol and ether, then in pure ether, then in very thin 
celloidin, and so on until they reach the thickest solution 
used. By this means the retina can be kept in situ; it 
usually becomes detached if it is put at once into strong 
alcohol. 

Celloidin* is best bought in chips, which are dissolved 
as required. It is soluble in ether or absolute alcohol. 
The best way of dissolving it is to place some in a stop- 
pered bottle, and then to pour ether upon it until it 
is covered; after some hours it will be found to have 
partially dissolved, then acid an equal quantity of absolute 
alcohol. When used for embedding it should be of about 
the consistence of very thick collodion. 

If celloidin cannot be obtained, collodion may be used 
instead, but it is not quite so good. 

After the pieces of tissue have been well soaked, they 
are embedded hi paper boxes made as follows :— 



* Obtainable at Zimmerman, 9 and 10 St. Maiy-at-Hill, E.G. 



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OF THE EYEBALL. 



389 



G C , 


3 M 


1 \. 
1 \ 
\ \ 
' V 

\ V 

| s 

* \ 
\ \ 




•• 

• • 

/ i 

/* i 

* j 
* < 

e' • ! 








! F 

• r 

i r 
i ' 

. r 

* ? 
i * 

\ / 

\.r - - -. 




s 1 
\ J 

N 



A piece of white paper is taken and folded along the 
lines A A and BB» Then it is opened and folded along 
the lines CC and T)D, taking care that all the folds are 
pressed and well marked. 

Now make the two folds AE and CE come into con- 
tact; they are brought into apposition by making another 
fold outwards along the dotted line EG. The folds BF 
and FC are likewise brought together by means of the 
fold at the dotted line FG. The two projecting pieces of 
paper, BFCX and AECX, are then turned backwards so as 
to lie behind ABFE. 

The part which is standing upwards, and which corre- 
sponds to the free part of ABFE> is folded backwards 
across a line which would correspond to one drawn 
between the two points GG. 

Precisely the same thing is done on the opposite side, 
and we have a paper box with a handle on each side, thus — 




2 c 2 



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390 ON THE PATHOLOGICAL EXAMINATION 

A sufficient quantity of celloidin is poured into the box, 
and the specimen to be embedded is placed in it, great 
care having been taken to prevent the entrance of air 
bubbles. It is, as a rule, best to place the eye with the 
cut surface downwards, and with the convex side 
upwards. If a portion of the sclerotic be cut away before 
embedding, a ring of tissue is left instead of a hemisphere, 
and consequently there is less risk of getting air bubbles 
into the vitreous. When the back part of the eye is not 
required, it is much better to cut it away before putting 
it into celloidin, as it is easier to cut good sections from a 
small than from a large mass. 

After filling the box with celloidin and embedding the 
eye, it is placed under a bell jar for several hours, and if 
the celloidin has shrunk a good deal, it is replenished. 
After from 12 — 24 hours it is sufficiently hard to allow of 
its being placed into alcohol or methylated spirit to harden. 
It should be left here for at least 48 hours, and the 
longer it remains the better does the block become. 

When ready, the paper is torn away, and the block cut 
into a suitable shape for being placed on the carrier of the 
microtome. 

When cutting sections of tissues embedded in celloidin 
one or two precautions are necessary to be observed. 
The usual way is to cut under alcohol. . The block and the 
knife being completely immersed beneath the fluid, so 
that the sections, when cut, float away, and can be 
removed after a sufficient number have been made. A 
Katche's microtome is very convenient for this purpose. 

Another way is to use such a microtome as is made 
by Jung or Schantze; by means of these machines very 
excellent sections can be cut, but the knife and the tissue 
have to be kept continually flooded with alcohol. 

This, however, is not always necessary, as very thin 
sections can be cut when the knife and the block are 
quite dry — though care must be taken that the celloidin 
does not become so dry as to lead to its shrinking. The 



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OF THE EYEBALL. 391 

sections when cut coil up, but immediately unravel them- 
selves when placed in alcohol. In this way one can often 
get thinner sections than when the block is cut wet. 
Minot's microtome, with its modification for celloidin 
cutting, is an excellent machine. 

N.B. — When cutting sections in celloidin the knife 
must always be set very obliquely to the tissue so as to 
sweep slowly across the block. 

If very thin sections are required, while it is necessary 
to have the parts held together with celloidin, it is as well 
to use a mixture of both celloidin and paraffin, thus : The 
piece of tissue is dehydrated in absolute alcohol and put 
into celloidin as before. It is then taken and soaked for 
some hours in origanum oil, and afterwards placed in a 
mixture of origanum oil and paraffin heated to 35° C. 
Finally, it is soaked for an hour or more in liquid paraffin, 
having its melting point about 45°, and embedded. The 
sections can be cut as is usual for paraffin work, and a 
" rocking microtome " is excellent for the purpose. The 
paraffin can be dissolved out in mineral naphtha, and, after 
this has been well washed away with alcohol, the sections 
can be treated exactly like those cut in celloidin. 

Staining. — Any of the ordinary staining reagents may 
be used, but, perhaps, one of the simplest and most satis- 
factory is logwood and eosin. 

Ehrlich's acid hematoxylin* is one of the most satis- 
factory stains, and is made as follows : — 

Hematoxylin „ , .... 0*5 gram. 
Glacial acetic acid. . . . 2*5 c.c. 
Absolute alcohol . . . . "j 

Glycerine >aa. 25 c.c. 

Water J 

Alum in excess. 

Let the mixture stand in the light in a well-stoppered 

* Obtainable at Martindale, 10, New Cavendish Street, W. ; or Kanthack, 
18, Berners Street, W. 



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392 QN THE PATHOLOGICAL EXAMINATION 

bottle, and occasionally admit air. It improves by keep- 
ing, and stains well,. It may also be used for staining in 
bulk. 

The following is the procedure : — The sections are 
taken out of alcohol and put in distilled water. From 
here they are placed in the logwood, which should be 
diluted with distilled water until it is only just coloured. 
The sections may remain in this for 24 hours or more. 

They are then placed in ordinary tap water so as to 
neutralise the acid logwood and to obtain the blue colour 
instead of the red which the solution stains them. If the 
water is not sufficiently alkaline the addition of a little 
bicarbonate of soda will suffice to make it so. 

This acts as a very efficient nuclear stain, and, in 
order to have a contrast stain for the ground substance, 
they are placed in a weak watery solution of eosin for a few 
minutes, or, better still, in a very weak solution for some 
hours, but care must be taken not to over-stain in this, as 
much of the contrast is lost if this be done. 

After the eosin they are washed in water and dehydr- 
ated in alcohol or- pure methylated spirit* They are now 
ready for " clearing," This cannot be done in the usual 
way with oil of cloves, as this reagent dissolves out the 
celloidin, which is undesirable. The following method 
answers very well :— 

Place the stained section which is to be mounted in a 
mixture of equal parts of absolute alcohol and chloroform, 
then drop a cover-glass into, the fluid, and, while lifting 
up one side of it with a pair of forceps in the left hand, 
carefully spread ou,t the section on it with a teezing 
needle held in the right hand, while it is still beneath the 
fluid. Quickly remove the cover-glass with the section, 
run the excess of alcohol onto blotting-paper, and, as 
rapidly as possible, put it on a slide on which is a drop of 
Canada balsam dissolved in xylol. Now warm the slide 
over a spirit lamp to drive off any excess of chloroform 
and alcohol which may be left behind, but care should be 



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OF THE EYEBALL. 393 

taken not to heat it sufficiently to cause the balsam to boil, 
if this is done the preparation becomes full of air bubbles. 
The specimen is then ready for examination. 

Another way of clearing the section is with carbol 
xylol, which is made thus : — 

Carbolic acid . . ... 15 c.c. 
Xylol 44 „ 

Sulphate of copper . 0*1 gram. 

The sections, after having been in methylated spirit, 
are passed for a second or two into absolute alcohol and 
then into the clearing solution. They are removed from 
this with a section lifter and placed on a slide, when, after 
the excess of fluid has been run off, they are mounted in 
the usual manner in Canada balsam. 

Embedding in paraffin has several disadvantages, but 
there is nothing like it for cutting very thin sections, and 
it is, therefore, useful when a very minute examination of 
a tissue under the high power of the microscope is 
required. A good deal of labour is saved if the tissue is 
stained in bulk before it is cut. One of the most con- 
venient stains is borax carmine made as follows : — 

Carmine 0*5 gram. 

Borax 2 grams 

Distilled water . . 100 c.c. 

Heat the mixture and keep on stirring until it boils, then 
and add acid acetic dil. B.P 4*5 c.c. 

The following is the method adopted : — The piece of 
hardened tissue is put into borax carmine for two days ; 
it is then removed and placed, for 24 hours, in acid alcohol 
made by adding 1 c.c. of hydrochloric acid to 100 c.c. of 
alcohol (70 per cent.). This is then thoroughly removed 
by washing in water. 

Afterwards it must be dehydrated with alcohol and 
soaked in xylol or turpentine for 24 hours. It is now 
ready to be transferred to melted paraffin. This can be 



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394 ON THE PATHOLOGICAL EXAMINATION 

obtained with a melting point at various temperatures. 
That which becomes fluid at from 45° to 50° C. is perhaps 
the most convenient, as tbis degree of heat does no damage 
to ordinary tissues, and yet it is sufficiently firm, even at 
a summer temperature, to work with without difficulty. 

An oven or water bath must be obtained which can be 
heated with a gas-jet governed by a regulator which will 
not allow the temperature to rise more than a degree or 
two beyond the melting point of the paraffin. A piece of 
tissue may be left in this for a variable period of time, 
from one to six hours, according to its nature and size. 

After this it is embedded in the liquid paraffin, and 
allowed to cool. The best way to do this is to have 
two pieces of lead made in the shape of an L, the long 
leg measuring If inch and the short 1^ inch, the thickness 
being about § inch. Now, if these are put together thus 
£], a cubical-shaped mould is formed. 

If, now, these pieces of lead are placed on a sheet of 
glass, the liquid paraffin can be poured into the hole 
and the piece of tissue embedded in it. As soon as ever a 
film has been formed on the surface of the mass, the 
glass plate should be taken and flooded with cold water, 
which, in a few seconds, can be allowed to flow over the 
whole mass. Another simple way is to embed the tissue 
in paraffin on a watch-glass, and then to float it in cold 
water, so as to cool it as soon as possible ; or a label may 
be wrapped round the upper part of a cork and allowed 
to project sufficiently beyond the end of it to form a cup 
into which the liquid paraffin is poured. It is important to 
cool the block rapidly on account of the tendency the 
paraffin has to become crystalline and friable if it be 
allowed to set slowly. After this is clone, the mould may 
be taken away and the block is ready to be cut on the 
microtome. 

The " Rocking Microtome," made by the Cambridge 
Scientific Instrument Company, and Minot's microtome are 
commonly used in this country. By these machines ribbons 



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OF THE EYEBALL. 395 

of sections can be out — but any good microtome may be 
employed. It must, however, be remembered that in cut- 
ting sections in paraffin it is necessary to set the knife at 
right angles to the mass so that it is not drawn obliquely 
across the block as when cutting sections in celloidin. If 
the tissue has been already stained, the sections require 
only to be freed from the paraffin and mounted. 

This is done as follows : — 

Dissolve the paraffin out by placing the sections in 
turpentine or mineral naphtha, and wash this away by 
passing them into absolute alcohol for a few minutes. 
From here they are put iuto oil of cloves in order to clear 
them, and then mounted in Canada balsam. 

The best way of transferring a section from the oil to 
the slide is the following :— 

Place a flat section-lifter beneath the section, and then, 
very carefully, spread the latter out with a needle until all 
folds have disappeared; then, suddenly, raise the lifter 
out of the fluid, and in this way the section will be 
removed, together with a large drop of oil. Now let 
the oil float the section off on to a slide, and gently place 
it in proper position, when any little unevenness may 
be got rid of by touching it with two needles; but 
the section now will stand hardly any manipulation, and, 
therefore, it is important to have got it as flat as pos- 
sible before removing it from the oil of cloves. The slide 
is next stood up on end and allowed to drain for a few 
minutes. In this way the greater part of the fluid will 
flow away from the section. It is however, sometimes 
advisable to remove all the oil possible, and, to do this, the 
following plan is most useful— and qrute safe :— Hold a piece 
of fine filter-paper over the section, and press it firmly 
on to the left hand end of the slide ; then let it fall on the 
section, and rub the paper two or three times from left 
to right with the right middle finger so as to completely 
dry it. If the paper has been held firmly with the left 
hand so as to prevent its moving, the section will be 



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396 ON THE PATHOLOGICAL EXAMINATION 

found beneath it quite dry and flat and adherent to the 
slide. A drop of Canada balsam is now put on a cover- 
glass, and this is gently placed on the seotion, care being 
taken to exclude air bubbles. 

This method of mounting is applicable to all speci- 
mens, except to those which are cut in celloidin. The 
special process for mounting sections embedded in this 
medium is described above. 

It frequently happens that after sections have been 
cut in paraffin they are too brittle to allow of being 
mounted or stained if the embedding substance is dis- 
solved out. 

The best way to get over the difficulty is to cement the 
section, with the paraffin still adherent, to the slide, and 
then to stain and mount it afterwards. There are several 
ways of doing this, but the following is one of the best 
methods. 

Mix together three parts of oil of cloves and one part 
collodion, and smear a thin layer on the slide. On this 
place a section, and heat it for several minutes over a water 
bath or in an oven at about 60° C. By this means the 
section becomes fixed. Another convenient method is to 
fix it with egg albumin in the following way : — 

Beat up the white of an egg and filter it, add an equal 
quantity of glycerine and an antiseptic to keep it, e.g., 
thymol or camphor. 

The section is made to adhere to the slide by means of 
a thin layer of this, which is heated sufficiently to coagu- 
late the albumin, thus fixing it. 

After this is done, the slide containing the section is 
immersed in xylol in order to remove the paraffin, this is 
in turn removed with alcohol, and then the usual process 
of placing in distilled water, logwood, alkaline water, 
eosin, alcohol, xylol, and Canada balsam. (It is more con- 
venient to clear sections mounted in this way in xylol 
rather than in oil of cloves.) 

N.B. — It greatly simplifies matters when using this 



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OF THE EYEBALL. 



397 



process to have a series of beakers containing a sufficient 
quantity of the various fluids to enable one to immerse 
the slide containing the section in them one after the 
other. 

Freezing and Cutting in Gum.— This method has 
been brought to its present satisfactory state by Hamilton, 
and the following are his directions for preparing the gum 
for embedding : — 

(a) Make a syrup of the strength of 28*5 grams of pure 
sugar to 30 c.c. of water. When the syrup is boiling 
saturate with boracic acid. Filter through muslin when 
cold, 

(b) Make a mucilage of gum acacia in cold water of 
the strength of 45«6 grams of gum to 2,400 c.c. of water. 
Saturate with boracic acid by boiling, and filter as 
before. 

For the freezing fluid take of the-— 

Syrup ,..-.... 4 parts 

Mucilage 5 „ 

Water 9 „ 

Boil the mixture and saturate while hot with boracic 
acid. Filter when cold through muslin. 

Before soaking the tissue in this, the hardening fluid, 
whatever it is, must have been thoroughly washed away 
with water. 

It is most important to leave the tissue soaking in the 
gum solution for some time. Generally, if a small piece 
of tissue only is being used, 24 hours is long enough, but 
it is far better to leave it soaking for several days to 
ensure its having been thoroughly penetrated. 

The sections, after being cut, are placed in warm 
water so as to get them washed free of gum. After this 
has been done, they can be stained and mounted as 
above described (pages 391 and 395). If Ehrlioh's haema- 
toxylin be used, the following is a summary of the different 
steps : — 



ERRATUM. 



398 ON THE PATHOLOGICAL EXAMINATION 

1. Distilled water for three minutes. 

2. Weak solution of Ehrlich's hematoxylin, 12 — 24 

hours. 

3. Water which is faintly alkaline, 15 minutes. 

4. Weak eosin, half hour or longer. 

5. Methylated spirit, five minutes. 

6. Absolute alcohol, five minutes. 

7. Oil of cloves, two or three minutes. 

8. Canada balsam. 

The amount of time taken up in staining the sections 
can be greatly reduced by using stronger solutions, but 
better results are obtained by staining for a long time in 
a weak dye than by a short time in a strong one, though, 
owing to the inconvenience of waiting so long, the latter 
process is frequently adopted. 

The method of mounting in Canada balsam is exactly 
the same as that described when speaking of sections cut 
in paraffin (page 395). 

Numerous other stains are applicable for the histolo- 
gical examination of the eye, but the logwood and eosin 
is one of the most useful for ordinary things, and there- 
fore I will not complicate matters by introducing into this 
paper others which the reader can, if he so desires, look 
up in any of the ordinary text- books. 

There are, however, several things in the eye which 
are not made visible except by special reagents, and I 
will now describe a few of them. 

Cornea. — The corneal corpuscles and nerves are best 
shown by staining with chloride of gold. 

The following is Ranvier's lemon juice method : — 
Pieces of fresh cornea are soaked in lemon juice, which 
has been filtered through flannel, until they have become 
quite transparent. Then they are washed quickly in 
water and soaked in a 1 per cent, solution of chloride of 
gold for 20 minutes; after this they are again washed, 
and placed in the dark in a vessel containing 1 part of 



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1 



OF THE EYEBALL. 399 

formic acid to 2 to 4 parts of water, and left there for 24 
hours. The tissue may then be frozen in gum and sections 
made. Numerous modifications of the gold method are 
used, but this one gives very satisfactory results. These 
sections should be mounted in glycerine, and the cover- 
glasses sealed at their edges with gold size or Dammar 
varnish. 

Nitrate of Silver staining is useful for demonstrating 
the cells on Descemet's membrane. A \ per cent, solution 
in distilled water is run over the tissue and allowed to 
remain on it for a few minutes, it is then exposed for 
several hours to light in glycerine, and finally mounted in 
Canada balsam. 

Another excellent nuclear stain is lithium carmine, 
made as follows : — 

Carmine 3*5 grams. 

Saturated aqueous solution of 

lithium carbonate. 100 c.c. 

If this is used for sections they must be washed for 
a minute in acid alcohol (1 cm. of hydrochloric acid to 
100 c.c. of 70 per cent, alcohol). They are then thoroughly 
washed in water, dehydrated in alcohol, cleared in oil of 
cloves, and mounted in Canada balsam. 

-This can also be used for staining in bulk. 

The glands of the ciliary body, as described by Mr, 
Treacher Collins, can only be demonstrated after remov- 
ing the pigment by bleaching. The following is his 
method of preparing them : — * 

1. Embed the anterior part of an eye in celloidin, and 

cut sections as above described. 

2. Soak them for three minutes in water which has 

been thoroughly shaken up with chloride of lime 
and then filtered. 

3. Transfer them to water acidulated with hydrochloric 

acid m. i to 3 i. 

# Trans. 'Ophtli. Soc> vol. xi. 



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400 ON THE PATHOLOGICAL EXAMINATION 

4. Pass the sections backwards and forwards in the 

solutions 2 and 3 several times. 

5. Place them in alkaline water containing Liq. 

Ammoniee m. i to 3 iv, so as to remove the chlorine. 

6. Wash thoroughly in several changes of distilled 

water. 

7. Stain and mount in the manner already described. 

Examination 0? Micro-organisms.-— It is often neces- 
sary to examine the secretions of the conjunctival sac for 
micro-organisms. It must be remembered, however, that 
in a large number of healthy conjunctival sacs micro- 
organisms can be found. Cocci of various forms and 
sizes are the commonest organism met with, and occa- 
sionally bacilli are seen. They are readily cultivated on 
agar-agar or on serum. 

Methods of Staining Micro-organisms, 

The following is a simple and very useful way of 
staining for most forms of organisms, though if it is 
necessary to distinguish minute differences other and more 
troublesome methods of staining must be employed. 

The first thing to do is thoroughly to clean two cover- 
glasses by washing them with acetic acid and drying 
them with a smooth duster. If the pus be abundant a 
drop may be taken and pat on a cover-glass, and then 
the second cover-glass is pressed on the top of the first, 
thus causing a thin film to remain on both when they are 
drawn apart; they are then allowed to dry. Another 
method is to put a platinum needle, which has been 
sterilised in a flame, into the pus and to smear it over 
a cover-glass upon which is a drop of sterilised water, 
this also is allowed to dry in the air. After it is quite dry 
(and not before) the cover-glass is held between the 
finger and thumb and passed quickly three times through 
the flame of a spirit lamp or Bunsen burner. A drop 
or two of the staining fluid is then put on the film 



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OF THE EYEBALL. 401 

and allowed to remain there for a few minutes, after 
which it is washed off with distilled water, the pre- 
paration being again allowed to dry in the air after 
any excess of water has been removed with blotting- 
paper, but great care should be exercised not to touch 
the stained film. When perfectly dry, it is mounted 
on a slide in a drop of Canada balsam. There are seen 
to be numerous pus cells which are stained, but the 
organisms are much smaller, and as a rule more deeply 
coloured than these. 

It is extremely convenient to have a pair of forceps 
Avhich open only when pressed, to hold the cover-glass 
during all the manipulation. In this way it is impos- 
sible to mistake on which side of the cover-glass the 
film is. 

Loffler's methylene-blue solution is particularly 
useful for staining most ordinary organisms, though it is 
not a good stain for photographic purposes ; it is made as 
follows : — 

Strong alcoholic solution of methylene- 
blue 15 c.c. 

Caustic potash, 0*01 per cent 50 „ 

Another useful one is an aqueous solution of gentian- 
violet. Its power of staining is increased by dissolving 
it in aniline water, which is a 1 per cent, solution of 
aniline oil in water ; the mixture is well shaken, and 
then filtered, a little alcohol being first added to dissolve 
the oil. 

Carbol-fuchsine is particularly useful for tubercle, as 
well as for other bacilli; it may be made by adding 
5 por cent, of carbolic acid to a solution of fuchsine in 
water. 

GfcAM ? s method is most useful for certain kinds of 
organisms, though useless for others. 

1. Stain for a few minutes in a saturated solution of 
gentian-violet in aniline water. 



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402 ON THE PATHOLOGICAL EXAMINATION 

2. Put the specimen in Gram's iodine solution for 1 to 
1^ minutes ; this is made as follows : — 

Iodine 1 part. 

Potassium iodide 2 parts. 

Water 300 „ 

3. Decolorise in alcohol until nearly all the colour is 
lost, 

4. Mount in Canada balsam. 

This stains, among other organisms, tubercle anthrax, 
leprosy, and tetanus bacilli, pneumococcus of Frankel, 
streptococcus of erysipelas, staphylococcus, pyogenes 
albus and aureus, &c. Some bacilli, such as typhoid and 
also gonococci, become decolorised by it. 

One may here give another stain for tubercle bacilli. 

Ziehl- Niels en's Method.— 

1. Make the following solution :— ~ 

Fuchsine 0*5 gram. 

Alcohol 5 c.c. 

Pure carbolic acid 2*5 „ 

Distilled water 50 „ 

Make a small quantity of this stain warm over a water 
bath, or by very cautiously heating it with a spirit lamp 
in a watch-glass. Place the cover-glass preparation^ made 
as before described, in this for from 3 — 5 minutes* 

2. Decolorise in dilute sulphuric acid 5 per cent. 

3. Wash in 70 per cent, alcohol. 

4. Stain for 1^- to 2 minutes in an aqueous solution of 
methylene-blue. 

5. Wash in water and allow it to dry, 

6. Mount in Canada balsam. 

It will then be found that the bacilli are stained red, and 
other things on the slide are stained blue. 

Staining Sections for Bacilli. — It is not often necessary 
to stain eye sections for bacilli, and when it is done it 



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OF TEE EYEBALL. 403 

frequently fails chiefly because it is so difficult tu cut 
sections in celloidin thin enough for this purpose ; but 
still in cases of doubtful tubercle, &c, where small pieces 
of the eye can be taken and cut without the dense 
sclerotic, it is quite possible to get good results. 

Similar methods are used to those above described 
when making cover-glass preparations, but, as a general 
rule, sections require rather more staining than does the 
fine film upon a cover-glass. The staining powers of most 
dyes can be increased by heat, so that the watch-glass or 
whatnot in which the sections are placed should be 
heated until vapour comes off the surface of the fluid. 

Gentian-violet is one of the best stains for bacilli in 
sections. Stain in a 2 per cent, solution of gentian- violet 
either watery or alcoholic, and leave the sections in 
this until they are much overstained. Decolorise in 
absolute alcohol. Clear in xylol and mount in Canada 
balsam. 

Gram's method for staining cover-glass preparations of 
bacilli has already been described, and the process is the 
same when using the stain for sections, but it is as well to 
have stained the tissue first with lithium carmine ; it must 
be remembered that sections take longer to stain than do 
cover- glass preparations. 

GonococcL — These organisms are of the greatest in- 
terest in ophthalmic work, as it is often difficult to be 
sure, in an early stage, whether an acute ophthalmia is 
really of gonorrhoeal origin or not. It is of the utmost 
importance to determine this at once both from the point 
of view of treatment and also from legal questions which 
may arise. 

These organisms are generally easy to find if they are 
present, and their appearance is so characteristic that 
they are readily recognised. They are described by 
Fliigge as follows : — a The cocci almost always occur in 
the form of diplococci. The elongated body of the diplo- 
coccus in stained specimens shows a middle clear line 
VOL. xiv. 2 D 



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404 ON THE PATHOLOGICAL EXAMINATION 

(best seen in fuchsine preparations), whioh, with the 
highest powers, appears as a distinct partition ; this line 
divides the coccus into two halves, and gives it the roll 
(bisouit) form. As a rule, the two halves are not true half 
circles ; at times a slight concavity is present on the 
opposed and flattened surfaces of the hemisphere. 

" The cocci in gonorrhoeal secretion lie chiefly on or in 
the pus cells, in small, irregular heaps,- . , , they really 
lie in the protoplasm of the cell." 

One of the most ready ways of staining gonocooci is 
the following :— 

1, Smear a little of the discharge or conjunctival secre- 
tion on a cover-glass with a platinum needle, upon which 
is a drop of sterilised distilled water. Allow this to dry, 
but be very careful not to overheat it if it is held over a 
flame to hasten the process. After it is quite dry, pass it 
quickly three times through the flame of a spirit lamp. 

2. Pour a small quantity of an alcoholic solution of 
eosin into a watch-glass, and in this place the preparation. 
Warm this gently, and allow it to remain for about three 
minutes. 

3, Remove the excess with filter paper. ■ 

4. Stain for half a minute in a saturated alcoholic solu- 
tion of methylene-blue. 

5, Wash in water and dry. 

6. Mount in Canada balsam. 

The organisms are stained blue, and the pus cells, &c, 
red. 

Trachoma. — Numerous organisms have been described 
as being the cause of trachoma, and most of them rest on 
very little sound evidence. Cocci, bacteria, and even 
mould fungi are readily discovered in mast healthy con- 
junctivas, but no undoubted organism has yet been dis- 
covered to be the true cause of the disease. 

Some authors, e.g, y Ridley (Trans. Ophth. Soc, 1894), 
are inclined to think that a protozoa is the cause; while 
others, e.g.., Michel (Archives of Ophth., vol. xv) ? describe 




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of the Eyeball. 405 

a diplococcus Somewhat resembling the gonococcus, but 
smaller. 

Without definitely giving ail opinion as to what the 
real organism is, one may say that all these^ from tracho- 
matous and other eyes, can be readily stained with 
Gram's method, or in the way described above, when 
speaking of the gonococcus* 

The Xerosis bacillus consists of short, rod-shaped 
organisms, which grow readily in agar, and still better on 
serum, They stain well with Loffler's methylene-blue.^ 

Diphtheria bacilli are short, rod-shaped bacilli, which 
stain well with Loffler's blue solution previously described, 
These bacilli are decolorised with Gram's method. 

It is impossible, in a short paper like this, to go much into 
detail, or to describe any but the most common and useful 
methods of dealing with the pathological material likely 
to be met with in ophthalmic practice. For those who 
wish to investigate things more minutely, I could not refer 
them to two better works than. Methods of Pathological 
Histology, by C-. von Kaldden, and translated into English 
by Dr. H. Morley Fletcher, and The Microtomist's Vade 
Mecum, by Arthur Bolles Lee. 



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406 



TOBACCO AMBLYOPIA r SOME CASES IN WHICH THE INTER. 
YAL BETWEEN CESSATION OF SMOKING- AND IMPROVE- 
MENT OF YISION WAS UNUSUALLY LONG-. 

By A. H, Thomfson, 

The following four cases have been out-patients of 
Mr. Lawford's during the last three years* In all of them 
the diagnosis of tobacco amblyopia was ultimately justified, 
but the interval which elapsed before any noticeable 
improvement in vision took place was in two cases 
3 months, in one 7 months, and in one as much as 
a year. During these periods all four persisted in de- 
nying that they were smoking or chewing tobacco at 
all. The question as to then credibility can, I suppose, 
only be settled by the occurrence or non-occurrence of 
similar cases in the practice of others. If general expe- 
rience makes the occurrence of such cases not inherently 
improbable, we may, I think, look upon these cases as 
genuine, and say that the prognosis in cases of tobacco 
amblyopia may be kept in suspense for as much as a year. 
If otherwise, these cases only point to the necessity 
of great suspicion in regarding the statements of these 
patients. For practical purposes it may not, perhaps, 
matter much which view we adopt, though, from a 
scientific point of view, it is important* 

Case 1, — J, S<, est. 52, smokes 1| to 2 oz, " light shag," or 
" returns," per week. No spirits. Two months ago could 
read. 

June 1, 1895. R. 6/60 ; L. 6/60. 

Together, J. 13, c -h 2'0D. 

Discs normal. In R.., some Jens opacities, and one small 
yellow patch near the macula. Scotoma for red. 

August 31. No improvement. Has not used any tobacco 
or drunk any spirits. 

October 12. By October 1 his sight had improved suffi- 
ciently for him to work (brass-turning), Now : 



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TOBACCO AMBLYOPIA. 407 

R. 6/36, c + 1-0 D. 6/36, c + 3'0J.8; L. 6/36, c -f 2<5, 
6/36, c + 4-5, J. 8. 

From this time vision steadily improved for the next six 
months. 

March 21, 1896. R. 6/9, 2 letters ; L. 6/9, all. 

April 4, 1896. R. and L. together, 6/6. 

Here no improvement took place for three months 
Seven months later the cure was complete. 

Case 2.— S. B., set. 38. 

June 29, 1895. Sin ^es an ounce of shag a day. Drinks 
three or four pints of bcv.r- no spirits. . Sight failing three 
months. 

R. < 6/60, J. 16 ; L. < 6/60, J. 16. 

Central scotoma well marked ; absolute for reel. 

R. disc slightly pale on temporal side. L. large white 
/muslin patch" over greater part of optic disc. A few small 
yellow dots in macular region. 

August 17. R. < 6/60, J. 16; L. 6/60, J. 18, letters. 

September 21. Says he can see better at his work (fish- 
curer), but with test types cannot see 6/60, and only J. 15. 

December 11. Has been ill lately. Has not smoked. 

Still scotoma for red in both eyes. None for green. 

January 18, 1896. R. 6/60 ; L. 6/24, and J. 8, Hm. + 1 D. 

No scotoma for red now in either eye. 

April 18. R. 6/36, one letter; L. 6/24. 

June 27. R. 6/24, two letters; L. 6/18. 

August 18. R. 6/36, c + 1-0, J. 4 ; L. 6/18, c + 1, J. 1. 

There is still a small relative scotoma for red on temporal 
side of fixation point in R., and more doubtfully in L. 

In both R. and L. some superficial degenerative spots in 
macular region; more marked in L. R. has a small, crescentic 
muslin patch over lower and inner part of disc; much smaller 
than that in the R. 

November 23. R. 6/60, c + 1, J 12; L. 6/18, c + 1, J. 8. 

In this case, after three months no improvement could 
be demonstrated, and, owing to the complication with 

2 d 2 



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408 TOBACCO AMBLYOPIA. 

fundus changes, one might have given a worse prognosis 
than the event justified. 

Case 3.--J. E., set. 36. 

February 20, 1895. Smokes 2 oz. shag a week. Up till two 
years ago smoked 3 oz., 1-| to 2 pints of beer daily. 

R. Fingers at 2 ft. Failure dates from 3 J years ago. L. 
2/60. Failure dates from three years ago. 

0. discs pale and fluffy on surface. Central scotoma in each 
eye for red and green. Fields (?) slightly contracted or 
normal. 

May 4. R. 1/60 ; L. 4/60. 

August 2. R. fingers at 3 feet ; L. 4/60. 

R. large central scotoma for green, smaller one for red ; L. 
small scotoma for green, none for red. 

Neither field definitely contracted. 

August 17. To have galvanism to eyes. (Constant current 
daily, August 17 to August 24, and again September 1 to Sep- 
tember 28.) 

September 14. Says he sees more clearly. R. 1/60 on 
temporal side only ; L. 6/60. 

September 28. R. 3/60; L. 6/36. 

This improvement, which coincided with the use of 
the constant current, slowly continued after that treat- 
ment was stopped. 

October 24. L. 6/24 slowly ; c + TO, J. 4 at 8". 
November 9. L. 6/24 ; c ■+ 1*0, J. 2 at 6". 
December 11. c + 1"0, J. 1 at 6". 

Central scotoma in both eyes for green. No scotoma for 
red in either eye. 

January 11, 1896. R. 4/60; L. 6/24, and c + 1*0, J. 1. 

February 1. R. disc pale all over; L. more vascular. 

April 25. No change. 

May 23. L. 6/18, 2 letters. 

November 21. No improvement in R. ; L. 6/18, c + 1, J. 1. 

During the whole time that he has been under treat- 
ment this patient has always said that he was not smoking 
at all. 



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TOBACCO AMBLYOPIA. 409 

In this case the long period (seven months) before any 
definite improvement began may, perhaps, be connected 
with the very long period (3^- years) during which sight 
had been defective. (The apparent improvement between 
February and May, 1895, in as much as it did. not progress 
was probably not real.) The case presents some addi- 
tional features of interest : — 

(1) When improvement did begin, it coincided with 
the galvanic treatment. 

(2) A diminution of the scotomata for colour pre- 
ceded the improvement with the test type. 

(3) While the improvement of one eye was veiy con- 
siderable that of the other was very slight. The bad eye 
showed a very white disc without any definite contrac- 
tion of the field of vision. 

Case 4.— W. M., get. 54 

February 2, 1894. R. 3/60, J. 19 at 30 cm. ; L. 3/60, J. 18. 
Not improved by glasses. 

Scotoma in both eyes ; both discs pale. L. field normal ; 
R. nearly so. Patient used to smoke 2 oz. shag a week, but 
left it off since November, 1893. 

June 20, 1894. R, 3/60, J. 16, c + 3 ; L. 1/60, J. 16, c + 3. 

Some pallor of discs ; very little, if any. alteration in 
arteries. Media clear. 

October 24. Has been laid up six weeks with " rheumatic 
gout." 

R. 2/60, c + 1,5/60, J. 191 T ,, 

L. 2/60, c + 1, 3/60, J. 20 J ° + * & ' J * 16 ' 

January 1, 1895. R. 3/60 ; L. 3/60. 

April 4. R. c + 1-5, 6/60 1 6r6 
L. c + 1-5, 6/60 J /0 ' 

October 23. "Has not smoked at all." 

R. c + 2, 6/12 partly 1 . /Q ,-. 

L. + 2,6/18 J j 6 / 9 P-%- 

December 18. R. c + 2, 6/6 ; L. c + 2, 6j6. 

Here no noticeable improvement took place for a 



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410 TOBACCO AMBLYOPIA. 

whole year, during which the patient declared that he had 
not smoked at all. Yet, by the end of the second year, 
perfect vision was restored to each eye. Possibly the ill- 
ness which took place in the autumn of 1894 retarded 
recovery. 



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L 



411 



ON OPHTHALMIA NEONATORUM. 

By H. V, McKenzie and C. Devereux Marshall, 

There is, perhaps, no disease to which new-born infants 
are subject which is so destructive, if left to run its own 
course, or if treated improperly, as ophthalmia neonatorum, 
and it has been estimated that about 30 per cent, of the 
occupants of blind asylums are there as the result of the 
ravages of this disease. 

Although it is so frequently met with and can be so 
satisfactorily combated when seen early, yet it is aston- 
ishing how, in many cases, valuable time is lost in applying 
feeble and inefficient treatment, and it seems to be often 
disregarded or unrecognised until serious and often per- 
manent damage is done. 

However carefully the surgeon may treat the case, yet 
there are always a certain number which will have 
unsatisfactory results, and they are those in which the 
mothers, or the nurses responsible for the well-being of 
the children, neglect to follow the directions given. Such 
cases go on for weeks before getting well, whereas if 
they are properly attended to, the cure may with con- 
fidence be expected to be both rapid and complete. 

For the purpose of again bringing the facts of the 
disease and the details of treatment under observation, we 
hav- 1 thought it well to examine in detail 100 consecutive 
cases which have been treated at Moorfields, and as the 
entire management of the patients, so far as the surgical 
part of the treatment is concerned, has been carried out 
by one of us, it is easier to draw trustworthy conclusions 
from such a fairly large number of cases. 

Before entering into details, it may be well to mention 
the treatment which is invariably adopted, and which 
gives as satisfactory results as any we have tried. As 
soon! as the child is seen the discharge is wiped away. 






412 ON OPHTHALMIA NEONATORUM. 

and the eyes ate washed with boracic acid lotion. The 
corneas are examined, and any abrasion or ulcer is noted, 
special attention being paid to the situation 1 and depth of 
such. 

Both lids are then thoroughly painted with nitrate of 
silver, gr. x to 3 i, and the method of applying this is a 
point upon which we desire to lay great stress. It is of 
the utmost importance to thoroughly paint the whole 
conjunctival sac, and, inasmuch as not much more than 
half of the upper part is exposed when the lid is everted* 
it is necessary to sweep the brush underneath the lid, so 
as thoroughly to disinfect the cul^de-sac. The lower 
fornix must, of course, be treated in the 3ame manner, but 
as this is so much easier to accomplish, it is hardly likely 
to be neglected. The most effectual manner of clearing 
the upper fornix is to raise the lid, without necessarily 
everting it, to draw it away from the eyeball, and then, 
with a fairly large and moderately stiff earners hair brush, 
to apply the silver solution thoroughly to every part of 
the conjunctiva. In doing this, the brush should be kept 
well up against the back of the lid, so as to prevent 
injury to the cornea. If stringy pieces of coagulated 
discharge are brought away, the brush is cleaned, and 
after having again being charged With fresh solution, the 
same action is repeated until one is quite sure that all 
loose infective material has been removed. 

Great care should be taken in selecting a brush which 
is well made and which has no rough piece of quill 
projecting anywhere, as this is very likely to cause a 
small corneal abrasion, which will become infected, and 
thus act as the starting point of an ulcer. For a similar 
reason we are very strongly opposed to using the miti- 
gated stick, which is inferior in every way to the solution ; 
it could not possibly be applied thoroughly as above 
described, and may very likely do far more harm than 
good. The application of the pure stick is undei[ no 
circumstance whatever justifiable. The only reasor f< 



or 



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ON OPHTHALMIA NEONATORUM. 413 

stating this is the fact that at least one disastrous result 
has come under our notice where this was used elsewhere. 

The painting of the lids with the silver of the strength 
previously mentioned is continued daily until the discharge 
has nearly ceased, and then a weaker solution, e.g., gr. v 
ad g i niay be used occasionally. 

The following directions are given for treatment during 
the intervals between which the patients are seen : — 

The discharge is to be frequently washed away with 
cotton-wool soaked in boracic acid lotion, and once an 
hour a drop of nitrate of silver solution in the strength of 
gr. i ad g i, is applied. 

In those cases in which the cornea is unaffected, no 
other application is used, but should an ulcer be present, 
or the cornea be infiltrated, then atropine drops, gr. iv ad 
% i, are applied once a day. 

In none of these cases was eserine used, and owing to 
its myotic action, it appears to us to be hardly even 
indicated, though occasionally cases are -seen in which 
somewhat slow healing, and what might be termed chronic 
ulcers of the cornea, are greatly benefited by eserine. 
Such cases are very rare, and great harm is likely to result 
by the indiscriminate use of the drug in all cases of corneal 
ulceration. 

We will now examine the cases for the purpose of 
showing the state of the eyes before treatment was com- 
menced, and the condition of the cornese after the 
^k+kalmia had been cured. 

f the 100 cases here recorded, 

h eyes were affected in 95 — 190 eyes or 97*43 per cent, 
j eye only was affected in 5 „ 2*56 „ 

Total 195 eyes. 

he cornese were clear when they first came under 
vation in 161 or 82*5G per cent. 



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414 ON OPHTHALMIA NEONATORUM, 

The cornea was hazy, ulcerated 

or perforated in 34 or 17*43 per cent. 



195 99-99 

Of the 161 cases in which the cornea, when first seen 
was clear, their condition after the disease had run its 
course was as follows : — - 

150 or 93*15 per cent, remained clear. 
10 „ 6*21 ,, were nebulous. 

1 „ 0*62 ,, perforated, 

161 99^98 
Of the 34 cases in which the cornea was to a greater or 
less degree affected when first seen, their condition was 
as follows : — 

11 or 32*35 per cent, had already perforated. 

23 „ 67*64 „ were hazy, or had ulcerated. 



34 99-99 
We need say no more about the 11 which had perfo- 
rated, as no treatment would be likely to save them, but 
of the remaining 23, which were not so seriously affected, 
we find that their ultimate condition was that 

In 8 or 34*78 per cent, the cornea cleared up. 
„ 9 ,, 39*13 „ the cornea was nebulous. 

„ 6 ,, 26*08 ,, perforation took place. 



23 99*99 

The average duration of cases under treatment was 
11-61 days. 

The longest period of time which any case took U 
was 25 days (one case only). 

The shortest period of time was 4 days, of which 
were seven in number. 

No case was considered cured until not only h* 
discharge quite ceased, but the conjunctiva had ass 
its natural appearance, and no further treatment 
necessary. 



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Ophthalmic Hospital ReportSe 

Vol. XIV. Part III. December, 1807, 



METASTATIC CARCINOMA OF THE EYEBALL. 

By G. Dbyereux Marshall, Curator. 

CASE I. — Mrs. J. J., set. 57, was seen early in 1895, and 
was found to be suffering from a tumour of the right 
breast. It had all the appearances of being a scirrhus. 
On May 7, 1895, the breast together with the axillary 
glands were removed, and the diagnosis of scirrhus was 
confirmed by pathological examination. 

The wound healed slowly, but was quite closed by 
June 28. 

The patient remained in good health for about 17 
months, when she found the sight of her right eye failing. 

She was then seen by Mr. John Couper, who diagnosed 
an intraocular tumour. In December, 18-96, the eye was 
removed, and was sent to me for pathological examina- 
tion. Very shortly after this, patient developed ascitis, 
there was some pain and swelling of the right arm, and 
some pain also in the left arm, but no tumour could be 
feli:, and there was no sign of local recurrence. 

/ In March, 1897, death took place, and although no 
post- mortem examination was made, yet there was every 
in/dieatkm that the patient had secondary deposits in the 
abdormjvn which proved fatal, 

VOL. XIV. 2 E 



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416 METASTATIC CARCINOMA OF THE EYEBALL. 

The eye after removal was hardened in alcohol, and 
the following is the description of it. 

The cornea has been rendered opaque by the hardening 
fluid, but appears to be otherwise healthy. The anterior 
chamber is shallow, and the angle narrowed but not closed. 

The lens is healthy and in situ. The vitreous has 
mostly disappeared. Situated at the posterior part, and 
extending from a point 3 mm. beyond the optic nerve on 
one side, to a point 2 mm. in front of the equator on the 
other side, is a flat unpigmented tumour 2*5 mm. in thick- 
ness, forming in the choroid, which at the edge of the 
growth is seen to split, one part going in front and the 
other part behind the tumour. 

The retina is detached, both over the growth and at all 
other parts, and the subretinal space is filled with a large 
amount of coagulated albuminous material. The retina 
takes no part in the formation of the growth, but at one 
place it appears as if the neoplasm were invading this 
structure. 

Microscopic Examination. — The growth is, seen to be 
in the choroid, and splitting it near its edge, while the 
intermediate layers of connective tissue run into the 
tumour, and disappear. The mass consists of cells and 
connective tissue, but there is relatively little of the latter 
compared with the large amount of cells. It is in this 
interstitial tissue, which is evidently of choroidal origin, 
Avhere the only pigment cells present are scattered; these 
cells are very few and far between, and they certainly 
form no intimate part of the tumour, which is entirely 
devoid of pigment. The parenchymatous portion of the 
neoplasm consists of large glandular epithelial bells, 
which are grouped together into masses and bounded 
by connective tissue; this, however, does not penetrate 
between the individual cells, which are grouped together 
by themselves. The vessels are few, and run entirely ijn 
the connective tissue meshwork. \ 

In some sections the cells can be seen growi4g into 



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METASTATIC CARCINOMA OF THE EYEBALL. 417 

the adjacent retina, and the head of the optic nerve con- 
tains several processes of tumour cells which have been 
cut in section. 

The sclerotic is quite unaffected, though a little round 
cell infiltration is seen at certain parts upon which the 
growth is resting. 

There are numerous areas of degeneration in the 
growth, but owing to their somewhat broken up and un- 
stained appearance it is difficult to say what they are 
composed of. In all of them migratory round cells are 
seen to be infiltrating. 

Case II. — The following case is one of considerable 
interest as bearing on this subject, and although it is not so 
complete as that first described, owing to the fact that no 
pathological examination could be made, yet there can be 
no doubt but that the patien t was suffering from metastatic 
tumours of both eyes. For the notes, and for permission 
to publish the case, I am indebted to the kindness of 
Mr. A. E. Reynolds, under whose care the patient was, 
and to Mr. J. B. Lawford, who made the ophthalmoscopic 
examination. 

The patient was a woman 44 years of age, who was 
operated upon 18 months before for carcinoma of the 
breast; this diagnosis was subsequently verified by micro- 
scopic examination. 

In January, 1896, the following condition was noted. 
" Patient is a pale emaciated woman, with a dry skin, a 
hectic temperature, and a cough. 

" There is very little headache, no ocular pain, occa- 
sional sickness after food or medicine, usually following 
coughing. There is a family history of tubercle. She has 
lately had ' pneumonia ' of one lung, which has never 
quite cleared up. The urine contains no albumen. The 
right eye failed painlessly some weeks ago. The left eye 
failed 8—10 days ago, but the vision in this eye is said to 
vary considerably/'' 

2" E 2 



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418 METASTATIC CARCINOMA OF THE EYEBALL. 

Present State. — " Right eye, tension normal, pupil acts 
very sluggishly to light, V. = less than J. 20* Left eye, 
tension normal, pupil acts well to light, V. = J. 8 fairly." 

Ophthalmoscopic Examination. — " Right eye. All round 
the optic disc, and for some distance towards the periphery, 
the fundus appears grey, semi-opaque, and raised. The 
optic disc appears to lie in a hollow, and looks dark in 
contrast to the surrounding tissue. The retinal veins are 
large, not tortuous and not obscured. The arteries are 
about normal in size. No haemorrhages, and no patches 
of exudation. The opaque area is unevenly hyper- 
metropic, and the red reflex of the choroid quite lost. 
The media are clear.'-' 

" Left eye. There is a similar grey appearance over a 
large area up and in from the optic disc ; the patch is very 
opaque and soft looking, and apparently swollen. The 
retinal vessels have much the same appearance as in the 
right eye. There are no haemorrhages, the optic disc is 
not swollen, and the media are clear." 

■■"No observations on the field of vision could be made. 
Patient was seen in her own room, and was too feeble to 
allow of any prolonged examination. She became quite 
blind soon after, but no rise of intraocular tension occurred. 
She died in August, 1896, but no post-mortem examina- 
tion could be obtained. Death occurred from ' exhaus- 
tion.' No cerebral symptoms developed, and the vision 
at last was bare perception of light only." 

This condition of secondary carcinoma of the eyeball 
is, I think, sufficiently rare to make it worth while to 
put such cases on record, and when one mentions the fact 
that until 1890 only five were to be found described in 
literature, and also that in the Moorfields museum there is 
only one somewhat doubtful case, it is pretty certain that 
this form of tumour may be regarded as among the most 
uncommon neoplasms met with. 

Since 1890 several oases have been recorded, but still 



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METASTATIC CARCINOMA OF THE EYEBALL. 419 

the total number is so small that I venture to give an 
abstract of those which have been worked up and pub- 
lished, and in which there is undoubted evidence of the 
nature of the growth. 

Doubtless many other cases have occurred, which have 
neither been examined nor published, and I feel sure that 
were eyes more frequently investigated in persons suffering 
from malignant tumours, w r e should find that the condition 
is less uncommon than would appear on looking at the 
literature on the subject. 

Possibly the disease as it is here presented is of more 
interest to the pathologist than to the clinician, but as 
the former is almost entirely dependent upon the latter for 
his material, and as there is much room for work upon the 
subject of intraocular tumours, it is of the greatest im- 
portance that every case should be subjected to strict 
examination, if we are to elucidate the many perplexing 
cases upon which one is constantly asked to express an 
opinion. 

Perls was the first to describe a case of this condition, 
and the report is published in Virchow's Archives, vol. lvi, 
p. 437. The patient died of primary carcinoma of the 
hiigs and pleura, and at the autopsy the following con- 
dition was found in the eyes : — 

Left Eye. — Retina detached on the inner and lower 
sides. Along the -whole extent of the posterior half of 
the eyeball the . choroid is 2 mm. thick, quite hard, and 
almost like cartilage, forming a slightly prominent uneven 
surface. 

Right Eye. —There are several slightly prominent infil- 
trations, similar in appearance to the mass described 
above in the left eye. The retina is affected, and is per- 
forated at some places. Under the microscope the masses 
are seen to be of the nature of the primary growth, and 
in the capillary layer of the choroid, near the infiltra- 
tions, there are enlarged vessels filled with carcinoma 



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420 METASTATIC CARCINOMA OF THE EYEBALL. 

cells, thus forming emboli. No mention is made of the 
condition of the eyes during life. 

Microscopically Perls was able to trace a connection 
between the tubules filled with epithelial cells and the 
minute blood-vessels, thus showing that the metastasis 
was due to capillary embolism. 

Hirschberg has reported two cases. The first is 
published in the Centralblatt fur praktische Augenheil- 
kunde, 1882, p. 376, and also in Archiv fur Ophth., 1884, 
• Bel. xxx, Ab. 4, p. 113. The patient was a woman set. b2> 
who came in August, 1882, complaining of failing sight. 
She had suffered for nine years from cancer of the right 
breast. The glands in the right and left supra- clavicular 
region were enlarged. Externally the eyes showed no 
changes, but the vision of the left eye was much reduced. 
Both fundi showed some small pale yellow spots close to 
the disc. 

Six weeks later the right eye was still worse, and the 
ophthalmoscope revealed a similar condition in the two 
eyes, viz., a prominence of about 1 mm. 

In November R.V. = fingers at 5', and the growth was 
2 mm. high ; the retina was extensively detached. The 
vision of the left eye had become much worse; thfe 
growth was especially marked above the optic nerve. 

Later on the growth in the left eye also extended 
downwards from the papilla, so that on both sides there 
came to be a wall of new growth 12 — 15 mm. high. 
Along with this the vision rapidly failed, and then the 
growths began to shrink. There was never any pain in 
the eyes, and the tension was unchanged. Patient gradu- 
ally got worse and died early in 1883, but no post mortem 
was allowed. 

Scholer and Uhthoff (Centralblatt fur praktische 
Augenheilkunde, 1883, p. 23(5) record, a case of a woman, 
set, 33, who suffered from carcinoma of the breast for six 
years, This had been removed, .as far as possible by 
operation. The right eye was first affected. The retina 



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METASTATIC CARCINOMA OF THE EYEBALL. 421 

in this was extensively detached, the papilla swollen, 
and the retinal vessels dilated. Around the papilla 
was a greyish-white ring containing epithelial nests. 
On the retina of the left eye, in the macular region, were 
numerous greyish-white clots, about the size of pins' 
heads, without pigment. They rapidly developed during 
the 10 months the patient was under observation. The 
left optic nerve became atrophied and the right eye 
glaucomatous. 

The patient died shortly afterwards, when the condi- 
tion was verified by Uhthoff, who made the pathological 
examination. Metastatic growths were then found to be 
present in both pleurae, both ovaries, both cerebral hemi- 
spheres, dura mater, both eyes, and right optic nerve. 

The account of the autopsy is given in the Inter- 
national Beitrage zur wissenschaftlichen Medicin, ii, 1891, 
in a paper by Uhthoff, " Zur Lehre von dem metastatischen 
Carcinom der Choroidea." 

Hirschberg and Birnbacher (Archiv f. Ophth., 
1884, Bd. xxx, Ab. 4, p. 113) record the case of a woman 
28 years of age, who had had the right breast removed in 
January, 1884, for scirrhus. A short time before the left 
eye had failed. When first seen the right eye was normal 
in every respect, but the left was totally blind. It was 
entirely free from pain, and the T. was —1, and this 
condition remained throughout the whole course of the 
illness. Patient died in February, 1884. 

At the autopsy a wound in the region of the right 
breast was healing, but in it were two small nodules of 
growth. There were nodules also found in the lungs, 
bronchial glands, and sheath of the liver and kidneys. 

The eyeball on vertical section showed a large choroidal 
tumour, greatly diminishing the size of the vitreous cham- 
ber, and reaching as far forwards as the equator and 
backwards to the optic nerve. The retina was exten- 
sively detached by serous exudation. The base of the 
tumour measured 12 mm. long and 9 mm. in thickness. 



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422 METASTATIC CARCINOMA OF THE EYEBALL. 

The retina was funnel-shaped and in part adherent to the 
tumour. 

Microscopically the cells were of a large spheroidal 
glandular shape, being collected into groups, which 
were separated from each other by means of connective 
tissue containing pigment. At places the retina was 
invaded by tumour cells. 

The choroid in other parts was not altered in structure. 

Manz (Archiv fur Ophthalmologic, 1885, JBd. xxxi, 
Ab. 4, p. 101) describes the clinical appearances of a case 
of metastatic carcinoma of the eyeball which occurred in 
a woman get. 50, whose right breast had been removed 
for cancer in August, 1383. She was first seen on account 
of failing sight in November, 1883, when the operation 
wound had not quite closed, but there was commencing 
local recurrence, and the axillary glands were enlarged. 
Her general condition was bad. There was a large detach- 
ment of the retina in the right eye, and a similar condition 
was seen in the left. The tension was not increased. 
Both detachments increased rapidly, and patient became 
blind. The tension of the left eye fell slightly, but this 
was the only change from normal. The patient left the 
Clinic, but died shortly afterwards of recurrences in the 
abdomen. No post-mortem examination was obtained. 

A. Schapringer (American Journal of Ophthal- 
mology, 1888, vol. v, p.- 285). 

The case here recorded is that of n woman, a native 
of Germany, who was operated upon in 1885 for scirrhus 
of the right breast, the axillary glands being also removed. 
Microscopically the tumour proved to be a glandular 
carcinoma; the wound healed, and there was no local 
recurrence. In August, 1887, 22 months after the opera- 
tion, she accidentally discovered that the sight of the left 
eye had almost gone. Her strength (hen began to fail, 
and she had much shortness of breath. In October, 
3 887, there was found to be much pleuritic effusion on the 
right side. In November about three pints of greenish- 



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METASTATIC CARCINOMA OF THE EYEBALL. 423 

yellow fluid was withdrawn from the chest, but it reac- 
cumulated within two days. The patient speedily became 
worse, and died on December 27, 1887. The sight of 
the right eye was never impaired, and the tension of 
the left was normal throughout. A partial post mortem 
was made. The lower lobe of the right lung was per- 
meated with numerous cancer nodules, and the rest of 
this lung and all the left had nodules less thickly scattered 
through them. 

The liver was enlarged and hyperasmic, and contained 
numerous nodules similar to those found in the lungs. 
The stomach, heart, and pericardium were not affected. 
The left eye was removed, and after hardening was found 
to contain a flattened tumour on the temporal side. 
The choroid near the disc was much thickened, and com- 
posed entirely of carcinomatous tissue ; further forwards 
on this side it got thinner and thinner, until it nearly 
reached the ora serrata, where it ended with a bevelled 
edge. A few carcinoma cells were formed on the nasal 
side of the optic nerve, but the choroid here was practi- 
cally unaffected. 

Mitvalsky (Archiv f. Augenheilkunde, 1889, Bd. xxi, 
p. 431). The case here reported was that of a woman 
set. 46, who first noticed the sight of her left eye failing 
in February, 1886. The following is the history : — 

A carcinoma had been removed from her left breast in 
1884 ; a local recurrence, together with some enlarged 
glands, was excised. Since this time her condition has 
been good. When first seen, there were a large number 
of hard and enlarged glands in the axillary and clavicular 
regions, but no recurrence at the seat of the primary 
operation. 

Ophthalmoscopically a vertical oval growth of 3 disc 
diameters extended laterally from the papilla to the 
macula. The retina became extensively detached in the 
course of a few weeks. Shortly after this the eye showed 
the symptoms of acute glaucoma, and the globe was 



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4*24 METASTATIC CARCINOMA OF THE EYEBALL. 

excised. The right eye remained unaffected, but the 
patient died, with symptoms of metastatic growths in the 
lungs and brain. 

On examination the outer two-thirds of the choroid 
was replaced by a shell-shaped mass of a yellowish-grey 
colour, its greatest thickness being 2 mm. Microscopically 
the tumour presented the appearance of a carcinoma very 
like a scirrhus. It had numerous yellow spots, which 
did not stain, and which readily fell out when washed. 
The connective tissue framework showed everywhere 
choroidal pigment. The unstained areas were apparently 
formed of degenerated blood. The . papilla was not 
involved in the growth. The angle of the anterior cham- 
ber was normal, but the chamber itself had much fibrous 
exudation in it. 

The second case recorded in this paper is that of a 
man, set. 35, who came in October, 1887, complaining of 
failing vision in the left eye. He had had good health until 
a year previously. He then noticed a tumour of the left 
breast. This was removed, together with the axillary 
glands. Microscopically it proved to be a scirrhus. 
Ophthalmoscopically an irregular vertical tumour was 
seen extending from the macula. Its greatest elevation 
was 4 diopters. Tn. V. = 6/60> 

The growth developed rapidly, and patient died in 
December, 1887, with numerous metastatic growths, and 
with cerebral symptoms. 

Gayet (Archives d'Ophtalmologie, 1889, p. 205) re- 
ports a case of carcinoma of the right eye occurring in a 
soldier, set, 30, of alcoholic tendencies. 

When first seen by the author the right eye was quite 
blind, as the result of a detachment of the retina. It was 
very injected, tender, and painful, and prevented his 
sleeping. The diagnosis of intraocular tumour was made, 
and the globe was excised. 

On examining the eyeball after hardening, a large 
tumour of lenticular form was found touching the optic 



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METASTATIC CARCINOMA OF THE EYEBALL, 425 

nerve. Microscopically it was found to be composed of 
cylindrical shaped epithelium. The patient died shortly 
afterwards, with very marked abdominal symptoms. 
The post mortem revealed a large tumour of stomach, 
liver, and right lung. 

V. Kamoeki (Archiv fiir Augenheilkunde, Bd. xxvii, 
p. 46), reports a case which he had several years before 
published, as one of adenoma of the choroid. The 
eye, R., T. +, containing the growth, was removed in 
March, 1884. The patient was a man, ast. 37, who had 
always been strong and healthy. The eye began to fail 
about a year before excision, and for four months had 
been quite blind. The retina was completely detached, 
but the ciliary body and anterior part of the choroid were 
normal. Surrounding the optic nerve was a sharply de- 
fined tumour 5 mm. in height, and 18 mm. in lateral extent. 
In section the growth showed an alveolar structure. 

Microscopically the tumour consisted of glandular 
tissue, at some places resembling the lacrimal gland, and 
at others the thyroid. The epithelial cells were mostly 
cylindrical, and arranged in a single stratum. The peri- 
pheral portions had a structure like that of an acino- 
tubular gland. The stroma consisted of fibrous tissue, 
containing numerous choroidal pigment cells. 

Preparations from the central portions of the tumour 
closely resembled a cystoma of the ovary. These cavities 
were lined with flattened epithelium, and filled with 
colloid masses. From its close resemblance to other 
published cases of metastatic carcinomata of the choroid, 
and especially from its great similarity to Gayet's case, 
which, was secondary to carcinoma of the stomach, the 
author is strongly of opinion that this arose in a simi- 
lar manner. This, however, cannot be proved, but it 
was ascertained that shortly after the patieut left the 
hospital he became ill, and died in a few weeks, but with- 
out receiving medical attention. 

Schultze (Archiv fiir Augenheilkunde, vol. xxi, 1890, 



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426 METASTATIC CARCINOMA OF THE EYEBALL. 

p. 319) reports the case of a woman, ret. 34, who was seen 
in 1888, and who had noticed the sight of the left eye 
failing for about three months, accompanied latterly with 
pain and lacrimation. The external appearance of the 
eye was healthy. V. = 5/6. T. normal. 

Ophthalmoscopically a detachment of the retina was 
observed at the upper and outer part of the left fundus, 
but nothing like a tumour was seen. 

The patient had been operated upon for carcinoma of 
the right breast in December, 1887, at which time the 
axillary lymphatic glands were removed. 

In September, 1888, the blind eye was removed. The 
patient died five months later from recurrence in the 
nervous system, though no autopsy was aliowed. 

On examination of the eyeball the retina was found to 
be entirely detached. and the vitreous much shrunken. 

In the upper half of the eyeball there was a flat 
choroidal tumour lying on the sclera. It reached from 
4 mm. behind the ciliary body, and extended backwards so 
as to overlap the entrance of the optic nerve. The 
measurements of the tumour were 19 mm. x 16 mm., and 
its thickness was 5 mm. On the opposite side was another 
smaller deposit, 5 mm. broad and 2 mm. thick. 

Microscopically the tumours were shown to be of the 
same nature. The ground substance was composed of 
connective tissue containing numerous pigment cells, 
while the bundles of fibres enclosed groups of spheroidal 
epithelial cells. The vessels were not very numerous, and 
there were various patches of necrosed tissue ; in these 
spaces was a good deal of blood. 

A. E. Ewing (Archiv fiir Ophthalmologic, 1890, Bd. 
xxxv, Ab. i, p. 120) records a case of metastatic carcinoma 
of the choroid occurring in an unmarried woman set. 32. 
She was first seen in October, 1887. The sight of the right 
eye had been failing for two months, T. + 1. The retina 
was detached, and a growth could be seen at the base 
of the iris extending backwards into the ciliary body. 



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METASTATIC CARCINOMA OF THE EYEBALL. 4l i 

Ophthalmoscopic examination revealed a detachment of 
the retina, and a tumour spreading forwards into the 
ciliary body. 

The eye was excised in November, 1887. 

A carcinoma was then found in the left breast, about 
the size of an apple. 

At the end of December patient complained of dimness 
of vision of the left eye. A detachment of the retina was 
seen, and this rapidly increased in size. On examining 
the right eye after removal, a transverse section showed 
complete detachment of the retina and a gradual thicken- 
ing of the choroid in every direction from the optic disc 
to the equator, but nowhere was the tumour more than 
1*5 mm. in thickness. 

Microscopically the growth consisted of epithelial cells 
arranged in an alveolar manner in a connective tissue 
network. Numerous vessels were blocked with the cells 
of the new growth. 

The following clinical case is recorded by C. GliendG 
(Recueil d'Ophtalrnologie, 1890^ p. 325). Emma X, 
aet. 54, attended the clinique of Dr. Despagnet in Novem- 
ber 14, 1889, complaining of visual tremble in the right 
eye, following an injury with an umbrella nine months 
previously. 

For six months there had been repeated inflammatory 
attacks of periorbital pain and lacrimation. On exam- 
ination there was found to be intense ciliary injection, 
diminished tension, and other symptoms of cyclitis. 
Ophthalmoscopic examination showed an ill-defined de- 
tachment of the retina of + 6 D. The retina itself was 
greyish in colour. The patient had a cachectic appear- 
ance. 

For nine years she has noticed a tumour at the lower 
part of the right breast. It had increased much, and had 
now become ulcerated. 

By the end of February, 1890, patient had become 
very thiu and emaciated, and was confined to her bed for 



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■428 METASTATIC CARCINOMA OF THE EYEBALL. 

the greater part of the day. The eye again became 
inflamed, soft, and tender to the touch. The right tem- 
poral region had numerous blackish veins, very like that 
seen in some cases of tumour of the brain. 

On examination there were found to be undoubted signs 
in various parts of the body of neoplastic growths, in the 
skull, sternum, clavicles, some of the upper ribs, and in the 
fingers. 

The right breast, which was the seat of the primary 
growth, was entirely occupied by a hard mass the size of a 
fist, ulcerated at its lower part, and adherent to the 
pectoralis major. The left breast had a smaller tumour 
and the axillary glands were greatly increased in size. 
The liver was tender and enlarged, but she had never 
been jaundiced. The digestion was deranged, and there 
was frequent vomiting. The breast, the lungs, and the 
whole nervous system showed signs of being involved, 
and the patient became extremely weak. 

In order to examine the breast tumour Guende re- 
moved a small piece, but unfortunately the. examination 
proved inconclusive. 

The mother of the patient died of cancer. 

A. Elschnig (Archiv fur Augenheilkunde, Bd. xxii, 
p. 149) reports the case of a woman, set. 57, who, in Feb- 
ruary, 1887, was operated upon for carcinoma of the left 
breast. Shortly afterwards a local recurrence took place. 
She first complained of failure of the sight of the left eye in 
December, 1887. Ophthalmoscopically there was seen to 
be a detachment of the retina, and this rapidly advanced, 
until in less than a month it became completely detached. 
The intraocular tension soon became increased, and there 
was much injection of the eyeball. The glaucomatous 
condition continued until March, 1888, when the patient 
died from exhaustion, with metastatic growths in the 
brain, lungs, and liver. 

The affected globe was removed, hardened in Muller's 
fluid, and presented the following condition : — 



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METASTATIC CARCINOMA OF THE EYEBALL. 429 

The lens and iris were pushed forwards, the retina 
was completely detached, and the subretinal space was 
filled with coagulated albuminous material. The choroid 
near the disc was twice its natural thickness, of a mottled 
light brown colour, and sharply defined from the dark, 
atrophic, unthickened choroid. 

Microscopically the tumour was seen to be composed 
of dense fibrous tissue, containing pigment cells and a few 
blood-vessels. These bundles enclosed tubules of small 
epithelial cells, in many of which were cavities filled with 
degenerated matter or rod blood corpuscles. Two vense 
vorticose which were examined had their lumen occluded 
partly by proliferated endothelium, and partly by epi- 
thelial groups lying in masses of coagulated blood, 
portions of which had undergone calcareous degenera- 
tion. 

O. P. Wadsworth (Trans. American Ophth. Soc, 
1890, vol. v, p. 654). This case is that of an unmarried 
woman, aat. 46, who was first seen on June 14, 1890, having 
had a dimness of sight for three weeks. There was a large 
detachment of the lower part of the retina. In order to 
determine whether a tumour was present or not a needle 
was thrust into the eyeball through the detachment. The 
point could be seen with the ophthalmoscope, and distinct 
resistance was felt to lateral movement; this settled the 
diagnosis of tumour, 

The previous history was that, 16 months before, the 
right breast had been removed for cancer, which, however, 
was not nricroseoped. 

On June 26 the vision was reduced to P.L., and there 
was no fundus reflex. The eyeball was enucleated, and 
examined after hardening. The following condition was 
found, 

The vitreous was stained with blood. The tumour, 
which was situated in the choroid, was light in colour, 
moderately firm, nearly circular, with a smooth surface. It 
measured superficially 10 x 12 mm. and 3 mm. in thick 



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430 METASTATIC CARCINOMA OF THE EYEBALL. 

ness. At the anterior part of the growth and forwards to 
the ora s errata the retina was loosely detached, but it 
was in situ at all other parts. 

Microscopically the tumour consisted of masses of 
cubical and irregular-shaped epithelial cells, with areas of 
hyaline degeneration. It was situated in the choroid, but 
had invaded the inner layers of the sclerotic; the retina, 
however, was not involved. The subsequent history is 
not given. 

UhthofF (International Beitrage zur wissenschaft- 
lichen Medicin, 1891, Bd.ii). In an article in this volume, 
entitled " Zur Lehre von dem metastatischen Carcinom der 
Choroidia," "Uhthoff describes the case of a woman, set. 4 7 
years, who was first seen on January 6, 18H0, complaining 
of failing sight. She had had a carcinoma of the right 
breast operated upon in May, 1889. 

The vision of the right eye was 14/200, and of the leit 
3/200 ; in the right eye the upper half of the field was gone, 
and in the left there was a large central scotoma. Both 
retinas were extensively detached. Patient became coma- 
tose, and died on February 19, 1890. 

An autopsy was made by Dr. Oestreich the following 
day. There was a local recurrence in the right breast. 
There were also metastatic growths in the liver, spleen, 
kidneys, bronchial glands, retroperitoneal glands, right 
suprarenal capsule, right temporal lobe, and in the choroid 
of both eyes. 

Carl Wagner (Ueber m.etastatische Aderhauttu- 
moren, published in 1891 by Gustav Schroter) describes 
the following case : — 

On April 24, 1890, a man, set. 45, came to the Uni- 
versity Eye Clinic, at Halle, complaining about the left eye, 
which was blind; the conjunctiva was injected and chemo- 
tic. The cornea, aqueous, and lens were clear. The 
retina was entirely detached. Tension +. R. eye nor- 
mal. Sarcoma of choroid was diagnosed, as there was 
nothing to indicate carcinoma. Excision was advised, but 



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METASTATIC CARCINOMA OF THE EYEBALL. 431 

patient would not consent until four months later, when 
the eye was removed. 

On section, a flat tumour, about 2 mm. in thickness, 
was observed which had an extremely uneven surface. 
The retina was detached. 

Patient then gave the following history : — 
A year and a half previously the sight began to fail, 
and since then he had had several attacks of acute glau- 
coma, lie was seen by Schwalbe, who found the eye 
inflamed, painful, and blind. The retina was .detached. 
. In November, 1888, he attended a clinic at Leipsig, when 
a tumour the size of a pea was seen on the nasal side by 
means- of focal illumination. 

Two days after the operation, patient was carefully 
examined, when everything was found normal except the 
liver, which was enlarged and painful on pressure. Four 
months later patient again attended complaining of pain 
in the hepatic region. He was cachetic in appearance 
and had swollen glands in the neck, right axilla, and 
inguinal region. There was a distinct tumour of the 
liver, which had an uneven surface, and reached as low 
as the umbilicus in the middle line. There was slight 
ascitis. 

Pathological Examination of the Eye. — The angle of the 
anterior chamber was closed. The sclera was normal. 
Close behind the equator a tumour the size of a pea v^as 
seen connected with the choroidal growth. The growth 
itself was flat and shell-like in shape, and was nowhere 
more than 2 mm. in thickness. Microscopically the tumour 
was found to be composed of round or polygonal cells with 
round nuclei; they were arranged in an alveolar manner, 
while at places the cells were degenerated. 

The patient died subsequently of cancer of the stomach 
and liver, but he was not under observation at the time, 
and no post mortem was obtained ; consequently it is 
doubtful if the growth in the eye was primary or 
secondary. 

VOL. XIV. 2 F 



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432 METASTATIC CARCINOMA OF THE EYEBALL. 

The slow course of the disease, however, was very 
suggestive of the stomach being the primary source. 

Ward A. H olden (Archives of Ophthalmology, 1892, 
vol. xxi, p. 76) reports a case of carcinoma of the eye- 
ball, but the clinical history of the patient, from whom the 
eye was removed, was lost, therefore nothing but the 
anatomical and histological appearances are described. 
On opening the globe the retina was found detached on 
the temporal side from the papilla to the ora serrata, and 
the subretinal space was filled with a coagulated albumin- 
ous mass. Beneath this was a flat growth in the choroid 
1*5 mm. thick. 

In the outer layers of the sclera and in the episcleral 
tissue, at a point corresponding to the middle of the 
choroidal growth there was a small tumour consisting of 
narrow epithelial tubules, but it was separated by un- 
changed sclera from the other growth. 

Again, at a point 4 mm. to the nasal side of the papilla 
a few carcinoma tubules had developed in the choroid 
without causing any perceptible thickening. There were 
thus three distinct foci. 

That these three tumours were of metastatic origin is 
proved by the fact that two of the three deposits occur at 
a situation in which primary carcinoma does not occur, 
and this is also confirmed by their position with reference 
to the arteries. 

The smaller choroidal focus appeared in that portion of 
the choroid to which the short ciliary arteries of the nasal 
side run. The middle portion of the larger choroidal 
focus was in that part of the choroid where the greater 
number of the short ciliary arteries enter. 

The scleral focus was in the situation of the small twigs 
which, after being given off by the short ciliary arteries 
run near the surface of the sclera. 

S. Schllltze, (Archiv fur Augenheilkunde, Bd. xxvi, 
1893, p. 19) reports the case of a lady, set, 39, who was 
in good health until August, 1889. She was at that time 



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METASTATIC CARCINOMA OF THE EYEBALL. 433 

suffering from subacute catarrh of the lungs. She had 
repeated pulmonary hemorrhages, but no consolidation 
could be found, and there was no fever. In December 
she developed an empyeema, and 4—5 litres of seropuru- 
lent fluid were removed. 

In February, 1890, the sight of the left eye began to 
fail, and in the course of six weeks it became blind and 
painful. 

In May the eye was enucleated, as a tumour was 
suspected. Her general condition did not improve, and 
the pleural cavity was again aspirated. She died of 
marasmus in September, 1890, this being nine months 
after the chest symptoms developed. 

During life malignant disease of the lungs and pleura 
was diagnosed, but an autopsy was not permitted. 

The eye containing the growth was healthy in its an- 
terior part. Growing in the choroid, and reaching from 
the optic disc to a point a few millimetres behind the ciliary 
processes, was a flat, nodular growth, measuring from 
17—20 mm. in all directions, and 3 mm. in its thickest part, 
which gradually became thinner as it passed into the normal 
choroid. The sclerotic had become perforated, and near 
the optic nerve a small round tumour had developed out- 
side ; this measured 6 mm. laterally, and 4 mm. in height. 
A narrow tumour mass passed through the sclerotic, and 
united the two. 

Microscopically the growth had an alveolar struc- 
ture, being composed of large and small cell nests of 
varying form, situated in a stroma of connective tissue 
containing many choroidal pigment cells. The carcinoma 
cells, and many of the nests had both old and recent 
hemorrhages. The growth outside the globe was similar 
in structure, but contained much dense connective tissue, 
the nests contained no haemorrhage, and there were no 
pigment cells in the stroma. 

The choroidal vessels contained no emboli of cancer 
cells, but in the sclera many vessels were occluded by them, 

2 f 2 



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434 METASTATIC CARCINOMA OF THE EYEBALL, 

and a posterior ciliary artery was plugged by a carcino- 
matous embolus for some distance. 

The patient died of marasmus, nine months after the 
chest symptoms first commenced to develop, seven months 
after the first disturbance of vision, and four months after 
the eye was removed. 

No post mortem was permitted, but the diagnosis 
made during life was that of cancer of the lung and 
pleura. 

G. Abelsdorf, (Archiv fiir. Augenheilkunde, 1896, 
vol. xxxiii, p. 34) reports a case of a woman, set. 44, who 
complained that for three weeks the sight of both eyes 
had been affected. 

Ophthalmoscopic examination revealed in the left eye 
a flat detachment of the retina on the temporal side, and 
in the right eye a detachment near the yellow spot. The 
tension of both was normal. 

A primary carcinoma was discovered in the right 
breast, which had been growing for a year. The patient 
died three months later. 

On section of the right eye there was a diffuse thickening 
of nearly the whole of the choroid. It began around the 
disc and passed gradually into the normal choroid near the 
ora serrata. Its greatest thickness was 2*5 mm. 

The retina was completely detached and the snbretinal 
space filled with coagulated masses. 

Microscopically the tumour had a typical carcinomatous 
structure. The parenchyma was composed of connective 
tissue forming alveoli which were filled with epithelial cells, 
the connective tissue at parts contained fixed and pigmented 
cells together with free pigment. The tumour also con- 
tained necrosed tissue, degenerated cells, free pigment, 
many red blood corpuscles, and small blood-vessels. At 
some points the capillaries of the choroid were surrounded 
with carcinomatous tissue, but they contained no emboli of 
carcinoma cells, whereas many emboli were present in the 
posterior ciliary arteries near their passage through the 



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"MRTASTATIC CARCINOMA OF THE EYEBALL. 435 

•sclerotic. The optic disc was infiltrated with epithelial cells, 
and so also was the root of the iris in the ciliary body at its 
lower and temporal, side; these passed through the filtra- 
tion angle into the anterior chamber and invaded the 
circular fibres of the ciliary muscle. 

The microscopic appearance of the left eye was 
much the same as that of the right. No direct con-- 
nection existed 'between the iritic and the choroidal 
tumours. 

Henry D. Noyes (Trans. American Ophtln Society > 
1897, p. 538) reports the case of a patient, eet. 55, who 
was seen on September 5, 1895. She was a stout and 
well nourished woman who had undergone two operations 
for cancer of the right breast, once in 1880 and agahi in 
1889. In 1893 she had a uterine tumour removed, but it 
is not known if this was of a nature similar to that in the 
breast. 

Ophthalmoscopic examination of the right eye showed 
a few vitreous opacities, and in the middle of the fundus 
a detachment of the retina was visible. Ten weeks later 
the detachment was much more marked and the lower 
half of the retina also. 

In May, 1896, the eye was excised on account of pain. 
On section a growth in the choroid was found, reachino- 
from the optic nerve nearly to the equator, its thickness 
was 1*5 mm.; the retina was totally detached. 

On microscopic examination " the thickened choroid 
presents numerous connective tissue trabecule©, lightly 
pigmented, enclosing numerous alveoli of various sizes. 
These alveoli are partly or wholly filled with cells which 
resemble epithelial cells. In many places the alveoli are 
only lined with these cells, the rest of the space being 
partly filled with fibrin. There are few vessels in this part, 
the vessels of the choroid proper being much reduced in 
size, and crowded into the anterior or posterior side of the 
new formed tissue. About the optic nerve entrance the 
alveoli are quite small and well filled with new cells." 



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436 METASTATIC CARCINOMA OF THE EYEBALL. 

George H. EEatthewsoil, at the Annual Meeting of 
the British Medical Association held at Montreal, 1897, 
reported a case of metastatic adeno-cavcinoma of the 
choroid. The patient was a lady, get. 48, who came to 
Dr. Buller complaining of almost complete blindness of 
the right eye of about three months' duration. The 
lower part of the retina was seen to be detached. Buller 
then made a scleral puncture, and drew off a considerable 
quantity of serous fluid, and found next day that the 
retina had gone back, but that at a short distance below 
the optic nerve there was a small flattened ovoicl swelling. 
There was a large firm nodular tumour of the thyroid r 
and the diagnosis of malignant growth of that gland with 
metastasis of the choroid was made. The thyroid was 
extirpated, and the right eye was enucleated. On opening 
the eye, a small flat ovoid tumour with roughened surface 
was found immediately below the optic nerve. Micro- 
scopically it was seen that the growth was chiefly in the 
choroid, the sclera and optic nerve being invaded to a 
slight extent by tumour cells, while the retina was un- 
affected. The minute structure of the thyroid tumour, 
and also of that in the eye, showed that it was a glandular 
carcinoma. 

Of the 24 cases here recorded, 18 were females and 
5 were males, while in 1 case, No. 18, the clinical history 
was entirely lost. 

Most of these cases occurred in middle-aged per- 
sons. The youngest recorded age at which the disease 
appeared was 28. This case (No. 4) was recorded by 
Hirschberg and Birnbacher. The patient suffered from 
carcinoma of the right breast. The two oldest cases were 
set. 57. One of these (No. 14), recorded by Elschnig, was 
that of a woman who suffered from cancer of the left breast, 
and the other one was the first of the two cases which 
have formed the basis of this paper. No. 23 in table. 

The tension of these eyes forms an interesting feature. 



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METASTATIC CARCINOMA OF THE EYEBALL. 437 

It was normal in 11 cases. 

„ + 7 „ 

5 5 ~" 5 5 ** >> 

,, not recorded in 8 „ 

Total . . 30 eyes for 24 persons. 

Here we see that the usual condition is to have normal 
tension, and the least common minus tension. These 
cases differ in this respect from the ordinary sarcomata 
which affect the choroid. . In a paper by the author, 
published in the Ophthalmological Society's Transac- 
tions for 1896, on the subject of tension in cases of 
intraocular tumour, it was shown that of the cases in 
which the ciliary body was not affected, 67'92 per cent, 
had increased tension and 30*10 normal tension. 

The difference, however, is not surprising when one 
considers the anatomical peculiarities of these tumours. 

These groAvths are nearly always flat and thin, and 
consequently they are Jess likely to lead to the pushing 
forwards of the lens and iris, and to the blocking of the 
angle of the anterior chamber, as is so notably the case 
in eyes containing choroidal growths far back. 

With regard to the position of the primary growth, it 
is at once apparent what a large proportion of the 
patients suffered from carcinoma of the breast; of the 24 
cases, 17 suffered from this disease, one being a male and 
the rest females. 

One male, Case 1, and one female, Case 10, suffered 
from primary cancer of the lung and pleura. 

The three who had cancer of the stomach were all 
males. 

One case, No. 22, suffered from primary cancer of the 
thyroid, and in one case, No. 18, both the sex and the 
seat of the primary growth were unknown. 

The times during which the patients have lived after 
the first symptom of the eye having become diseased is 
very variable, and is really a somewhat unimportant fact, 
depending, as it must, on a variety of accidental cireum- 



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438 



METASTATIC CARCINOMA OF THE EYEBALL. 



stances. The usual span of life in these cases is a few 
months. The longest period of time recorded is in Case 
17, by Wagner, in which the patient lived for two years, 
•while the shortest is about a month in Cases 4, 5, and 11. 

When one considers the anatomical position of the 
structures involved, it is hardly surprising to find that 
malignant metastatic deposits in the eye are very un- 
common. 

One of the most marked features concerning the dis- 
semination of carcinomata is the readiness with which - the 
lymphatic system becomes involved. The lymphatic 
glands in the neighbourhood of the primary growth are 
practically always the first to become affected, and it is 
frequently only at a late stage that there is positive 
evidence of the vascular system having become the means 
of carrying the tumour cells to distant parts of the body. 
Now it is quite certain that the eye can only become in- 
volved through the vascular system, as there is no lymph 
stream running from, say, the breast or the stomach to the 
eye. Consequently, one would expect that this organ 
would but rarely become affected, and that only in the 
later stages of the disease. 

This is exactly what we find in the majority of cases. 
If, therefore, there is reason to suspect the presence of 



No. 














of 


Author. 


Where published. 


Sex. 


Age. 


R. or L. 


Tension. 


case, 














1 


Perls ., 


Vircliow's Archiv, Bd. 56, . 


M. 


43 


H. and L. 




2 


Hirschberg 


Oentralbl. f. prat. Atigen- 
heilkunde, 1882, p. 376. 


F. 


52 


E. and L. 


R.n. 
L. n. 



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METASTATIC CARCINOMA OF TEE EYEBALL. 



439 



a tumour in the eye of a patient suffering from carcinoma 
elsewhere, it should at least put us very much on the look- 
out for confirmatory evidence of metastasis in other parts 
of the body, and of general dissemination of the growth. 

As far as treatment is concerned, in such cases it can 
obviously be only palliative, as it is hopeless to imagine 
that internal organs are unaffected if the eye is already in- 
volved. On the other hand, there is absolutely no reason 
why such eyes should not be removed ; they are liable 
to attacks of acute glaucoma, and may, if they ulcerate, 
become extremely painful, whereas excision at an early 
stage involves practically no risk, and at least one source 
of discomfort is done away with, while the patient loses 
but a useless organ. 

In conclusion, I have to express my indebtedness to 
Mr. Couper for giving me the eye to examine from Case 1, 
and to Sir William MacCormac for his notes concerning; 
the previous history of the case. 

I have to thank Mr. A. E. Reynolds and Mr. Lawford 
for placing the notes of Case 2 at my disposal, and for 
kindly allowing me to publish it. 

My thanks are also due to Dr. Gordon Byers for his 
assistance in helping me to work up the literature of the 
subject. 



Pathological examination 
of eyeball. 



Flat shell-like growth in 
choroid 2 mm. in thick - 



Eyes not removed. 



Seat of 
primary 
growth. 



Seat of secondary 

deposits other than 

eye, and result of 

post mortem, if 

obtained. 



Lime 



Carcinoma of 
R. breast, 



Various internal or- 
gans. 

Unknown. No post 
mortem obtained. 



Duration of 
life after 

eye was first 
affected. 



About 7 
months. 



Remarks. 



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440 



METASTATIC CARCINOMA OF THE EYEBALL. 



]S T o. 

of 

case. 



Author. 



Scholer and Uh- 
tlioff 



4 Hirschberg and 
! Birnbacher 



5 ! Manz 

Schapringer 

Mitvalsky 

Mitvalsky 

Grayet . . 



10 



Kaniocki 



Where published. 



Centralbl. f. prak. Augen- 
heilkunde, 1883, p. 236. 



Graefe's Archiv f. Oplith., 
1884, Bd. 30, Ab. 4, p. 
113. 



G-raefe's Archiv f. Ophth., 
1885, Bd. 31, Ab. 4, p. 
101. 

American Jour, of Ophth., 

1888, vol. 5, No. 10, p. 
285. 

Archiv f. Augenheilkunde, 

1889, Bd. 21, p. 431. 



Archiv f. Augenheilkunde. 
1889, Bd. 21, p. 431. 



Archiv. d'Ophtalmologie, 
1889, p. 205. 



Archiv f. Augenheilkunde, 
1893, Bd. z7, p. 46. 

(Case published several 
years before elsewhere 
as ademona of choroid.) 



Sex. 



F. 



M. 



M. 



M. 



Age. 



33 



28 



50 



51 



46 



35 



30 



37 



R. or L. 



R. and L. 



L. 



R. and L. 



L. 



R. 



Tension. 



R, T. + 1 
L. X. n. 



T. - 1 



R. T. n. 
L. T. -1 



T.n. 



T. 4 2 



T.n. 



T. + 



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METASTATIC CARCINOMA OF THE EYEBALL. 



441 



Pathological examination 
of eyeball. 



R. greyish- white ring 
around the optic disc. 
L. flat tumour of choroid 
1 mm. thick. 



Large choroidal tumour 
reaching from equator 
to CD., base 12 mm., 
and thickness 9 mm. 

Eyes not removed. Re- 
tina in both detached. 



Flat metastatic tumour of 
choroid. 



Flat shaped tumour of 
choroid at outer part 
2 mm. in thickness. 

Irregular oval tumour 
reaching 4 disc diame- 
ters outwards from disc. 
Eye not removed. 

Large tumour of choroid, 
lenticular in shape, 
touching the optic nerve, 
composed of cylindrical 
shaped epithelium. 

Tumour surrounding O.N. 
base 18 mm. long, height 
5 mm. Cylindrical 

shaped epithelial cells. 



Seat of 
primary 
growth. 



Carcinoma of 
breast. Re- 
moved. 



Carcinoma of 
R. breast, 
which was 
removed. 

Carcinoma of R. 
breast, which 
was removed. 

Carcinoma of 
right breast. 

Left breast, 
which was 
removed. 

Left breast . . 



Stomach 



? Stomach 



Seat of secondary 

deposits other than 

eye, and result of 

post mortem, if 

obtained. 



Post mortem subse- 
quently made by 
Uhthoff. Recur- 
rences found in both 
eyes, R. optic nerve, 
both pleurae, both 
ovaries, both cere- 
bral hemispheres, 
dura mater. 

Lungs, bronchial 

glands, sheaths of 
liver and kidneys. 



Recurrences in abdo- 
men, but no post 
mortem made. 

Lungs and liver 



Growths in lungs and 
brain. 



Growths in cranial 
periosteum and 

brain. No post 
mortem. 



Duration of 
life after 

eye was first 
affected. 



Lung, liver 



No post mortem made. 



Remarks. 



1 year. 



About 1 
month. 



About 1 
month. 



4 months. 



3 months. 



2 months . 



A few 

months. 



Rather more 
than one 
year. 



Patient died 
with cerebral 
symptoms. 



As patient died 
with abdominal 
symptoms, and 
as the tumour 
cells resemble 
those of sto- 
mach, it is sup- 
posed that he 
was suffering 
from cancer of 
stomach, to 
which eye tu- 
mour Mas se- 
condarv. 



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442 



METASTATIC CARCINOMA OP THE EYEBALL. 



No. 

of 

case. 



11 



12 



13 



11 



Author. 



Sohnltze. . 



Ewing 



Cruende . . 



Elschnig 



15 Wads worth 



16 



Uhthoff . 



Where published. 



Archiv f. Augenheilkunde, 
1890, Bd. 21, p. 319. 



F. 



Graefe's Archiv f. Ophth. 
Bd. 36, Ab. 1, p. 120. 



Ke:ueil d'Ophtalmologie, 
1890, p. 325. 



Archiv f . Augenheilkunde, 
1890, Bd. 22, p. 149. 



F. 



International Beifr, zur 
wissenschaftlichen Me- 
dicin, 1891, Bd. 2. 



Age. 



34 



E. or L. 



L. 



Tension. 



T. n. 



32 



54 



57 



R. and 4 

months 

later in L. 



L. 



Trans. Amer. Ophth. So?., ! F. 46 

1890, vol. v, p. 654. 



47 



R. and L. 



T + 1. 

T + 1 



T + 



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METASTATIC CARCINOMA OF THE EYEBALL. 



4±?> 



Pathological examination 
of eyeball. 



Flat choroidal tumour in 
upper half of eyeball, 
reaching from 4 mm. 
behind ciliary body to 
O.N. It measured 19 
mm. by 16 mm., and 5 
mm. in thickness. On 
opposite side a second 
smaller deposit 5 mm. 
broad and 2 mm. thick. 

R. choroid thickened in 
every direction from 
optic disc to base of 
iris, nowhere more than 
1'5 mm. in thickness. 
Microscopically it was a 
glandular carcinoma. 



Choroid near disc twice its 
natural thickness. Mi- 
croscopically tubules of 
epithelial cells in a pig- 
mented ground sub- 
stance. 

F] at t u m our m eas uring 
10 x 12 mm. and 3 mm, 
thick. Consisted, of 
masses of cubical epithe- 
lial cells with areas of 
hyaline degeneration in- 
volving sclerotic. 

| Flattened tumours in both 
I eyes. 



Seat of 
primary 
growth. 



Carcinoma of 
right breast. 



Seat of secondary 

deposits other than 

eye, and result of 

post mortem, if 

obtained. 



Nervous system, but 
no autopsy was ob- 
tained. 



Duration of 
life after 

eye was firs! 
affected. 



Remarks 



5 weeks. 



Left breast. 



Right breast ., 



Skull, sternum, cla- j 

vicles, upper ribs j 

and. fingers, liver, I 

lungs, heart and j 

| nervous system. | 



Clinical obser- 
vation only. 



Left breast ., ■ Brain, lungs and liver. 3 months.. Eye removed 

after death. 



Right breast. 



Eight breast . . 



Liver, spleen, kidneys, 
R. suprarenal body, 
r etro peritoneal 
glands, bronchial 
glands, hugs, R. 
temporal lobe. 



A few 

months. 



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444 



METASTATIC CARCINOMA OF THE EYEBALL. 



No. 
"of 
case. 



17 



Author. 



Wagner, C. 



19 Schultze. . 



20 



Abelsdorf 



21 



23 



23 




IS Holden, W. A. - 



Noyes, H. D. 



Matthewson 



Author's 1st case 



Ueber metastatisch er Acler- 
hautlumoren, Halle, 
1891. 



Archives of Ophth., 1892, 
vol. xxi, p. 76. 



Archiv f . Augenheilkuncle 
1893, Bd. 26, p. 19. 



Archiv f. Augenheilkuncle, 
1896, Bd. 33, p. 34. 



Trans. Amer. Ophth. Soc. 
1897, p. 538. 



Montreal Meeting of 
British Medical Asso- 
ciation, 1897. 



Present paper 



bex. 



M. 



¥. 



Aae, 



45 



R. or L. 



39 



44 



55 



48 



57 



L. 



R. and L. 



Tension. 



T. + 



T. n. 



R. 



T. slightly 



R. 



T. n. 



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METASTATIC CARCINOMA OF THE EYEBALL. 



445 



Pathological examination 
of eyeball. 



Flat tumour of choroid 2 
mm. in thickness. Tu- 
mour . cells are round 
and polygonal. 

Flat growth of choroid 
1'5 mm. Also small 
tumour on outer side o< 
sclerotic, but not con- 
nected with larger 
growth. Also a sepa- 
rate small growth in 
choroid. 

Flat nodular tumour of 
choroid 20 x 17 mm. 
and 3 mm. thick. Scler- 
otic perforated near 
O.D., and a tumour 
6 x 4 mm. outside scle- 
rotic, connected with the 
intraocular growth. 

R. flat tumour of choroid 
around disc, and extend- 
ing forward 2'5 mm. in 
thickest part. Another 
small growth at base of 
iris. The left eye shows 
a similar condition. 

Flat tumour reaching from 
O.D. to equator 1*5 mm. 
thick. 

Small fla* ovoid tumour 
with roughened surface 
immediately below op- 
tic nerve. 

Flat tumour extending 
from 5 mm. beyond O.N. 
on one side to 2 mm. in 
front of equator on the 
other. Growth is 2 "5 
mm. thick. 



Seat of 
primary 
growth. 



Probably 
stomach 



Probably lung 
and pleura 



R. breast 



R. breast 



Thyroid 



R. breast 



Seat of secondary 

deposits other than 

eye, and result of 

post mortem, if 

obtained. 



Grlancls of neck, axilla 
and inguinal region, 
liver. No post mor- 
tem obtained. 



Unknown, probably 
metastatic growth 
in abdomen. 



In abdominal viscera, 
but no post mortem 
obtained. 



Duration of 
life after 

eye was first 
a If ec ted. 



About 
years. 



7 months. 



4 months. 



Still alive. 



20 months. 



Remarks. 



Clinical history 
entirely lost. 



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446 



METASTATIC CARCINOMA OP THE EYEBALL. 



No, 

of 



Aufclior. 



Where published. 



24 Author's 2nd case j Present paper 



F. 



44 



R. or L. 



R. and L. 



Tension. 



T. n. in both 



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METASTATIC CARCINOMA OF THE EYEBALL. 



447 



Pathological examination 
-of eyeball. 


Seat of 
primary 
growth. 


Seat of secondary 

deposits other than 

eye, and result of 

jjost mortem, if 

obtained. 


Duration of 
life after 

eye was first 
affected. 


Remarks. 




Breast 




About 9 
Month?. 


Right eye failed 
slightly before 
left. Patient 
had " pneu- 
monia" some 
months before 
death. She 
died from "ex- 
haustion,'' and 
had no cere- 
bral symp- 
toms. No post 
mortem ob- 
tained. 



L. XIV. 



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448 



CONCOMITANT STRABISMUS : THE ACCESSORY ADDUCTORS 
AND ABDUCTORS. 

By J. Herbert Fisher, M.B., B.S. (Loncl.). 

In speaking of the movements of the eyes we are con- 
stantly meeting with the statement that pure lateral 
movements of adduction and abduction are effected by 
the isolated action of the internal rectus and external 
rectus muscles respectively. This is a statement to which 
I think few anatomists and physiologists agree, and 
which few ophthalmologists on consideration really, I 
believe, would accept. It is in the first place contrary 
to our knowledge of the behaviour of muscles elsewhere 
in the body ; in the movement, for example, of elevation 
of the hyoid bone and larynx, muscles such as the two 
digastrics and stylohyoids are provided to do the work 
which/' at first sight a single vertical muscle could effect, 
seeing that no lateral deviation of these mid-line struc- 
tures of the neck is required or allowed ; the movement 
restoring the hyoid bone and larynx to their positions of 
rest is carried out by the muscles of depression, the 
sternohyoids, and sternothyroids, neither of which run in 
the vertical direction, and by the digastric muscles, the 
omohyoids. We learn that these arrangements secure 
steadiness of action, and accept it as a satisfactory explana- 
tion, because it accords with our general examination and 
experience of muscles elsewhere in the body. Do we then 
really believe that Nature has been so remiss as to provide 
a single straight muscle to act alone in effecting a move- 
ment where delicacy, accuracy, and steadiness are per- 
haps more essential than any other of which we are 
capable? Still the fallacy is perpetuated in text-books, 
and, it seems to me, leads us into greater difficulties. We 
learn that in uncorrected hypermetropia the inability to 
dissociate the action of the converging internal recti from 



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CONCOMITANT STRABISMUS. 449 

the action of the ciliary muscles and pupillary sphincters 
results, especially when the correcting influence afforded 
by binocular vision is from any cause reduced, in pre- 
ponderance of the internal recti and convergent strabis- 
mus; when, however, in high myopia the incentive to 
convergence is that in order to get clear images the 
patient holds objects close to his eyes, we accept the 
statement that the internal recti refuse to respond to this 
stimulus, or if they do so for a time and have presumably, 
in consequence of much use, hypertrophied, in time of 
tribulation they fall away, and, declining further to make 
the efforts required, divergent strabismus is the result. 
Insufficiency of the adductors to maintain convergence 
in times when the general health is enfeebled Ave may 
believe, but insufficiency of these hypertrophied adductiug 
muscles to maintain the parallelism of the primary posi- 
tion against abducting external recti which, like- the 
myopes ciliary muscle are probably atrophic from di- 
minished use, is hard to accept. It comes to this, that in 
over use from one cause the internal recti hypertrophy 
and give rise to convergence, while in over use from 
another cause they perversely become enfeebled and 
allow divergence, when in either case binocular vision is 
impaired. 

We are led into these difficulties from regarding the 
lateral recti as the sole agents in providing pure lateral 
rotation of the eyes. There is, to my mind, no doubt 
whatever that the superior rectus and inferior rectus 
passing from their origins forwards and outwards to their 
insertions in front of the centre for lateral movement of 
adduction, can and do contribute to this movement, 
whether it be effected for convergence or in association 
with abduction of the fellow eye, In acting together the 
tendency of the superior rectus to elevate the cornea is 
neutralised by the tendency of the inferior rectus to 
depress it ; the rotation of the globe on the antero-posterior 
axis which the superior rectus tends to provide (wheel- 

2 G 2 



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450 CONCOMITANT STRABISMUS. 

like movement towards the nose") is counteracted by the 
opposite rotation on the same axis attempted by the 
inferior rectus. 

Superior rectus. . Elevator. Internal rotator . „ Adductor. 
Inferior rectus . . Depressor. External rotator. . Adductor. 

The quota of adduction contributed by each remains, 
when both act together, to supplement that of the pure 
adductor, the internal rectus. Here then we have three 
good muscles, all innervated like the ciliary muscle and 
sphincter pupillse by the third nerve, to effect steadily and 
with precision the most important movement of converging 
the eyes- on a near point. A control on their action is of 
course provided by the abductors, just as we do not flex 
our forearm with the biceps and its assistants without at 
the same time throwing into action the triceps and other 
extensors. 

The movement of abduction, similarly tabulating the 
muscle actions-, is seen to be performed by the two obliques 
with the external rectus — the pure abductor. 

Superior oblique. . Depressor. Internal rotator . . Abductor. 
Inferior oblique , . Elevator, External rotator. . Abductor. 

The movement of abduction, being one only of restitu- 
tion, is effected, it may be noted, by one muscle supplied 
by the third nerve, one by the fourth nerve, and one by 
the sixth nerve. 

With the eyes at rest in the primary position we 
must, I think, assume that the tone of the adductors 
is exactly balanced by that of the abductors; if not, 
movement would result ; the statement is also prob- 
ably true that the work done in adducting the eye 1° is 
equal to that done in abducting it to the same extent, 
though, without some means of estimating the resistance 
offered to the two movements, I do not think it is capable 
of proof; but in the position of rest, whether that be one 
of parallelism of the eyes or of divergent or convergent 



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CONCOMITANT STRABISMUS. 451 

strabismus, the adductors and abductors are balancing one 
another. Let us take the case of divergence of axes of 
the two eyes ; it is admitted by all that tenotomy of the 
external rectus will do less towards correcting a divergent 
strabismus that tenotomy of the internal rectus will do for 
a convergent strabismus ; regarding the lateral recti as 
the sole agents of lateral movement, the normally more 
powerful adductor, attached also at greater advantage 
(nearer the sclero-corneal junction), when its antagonist is 
divided and it is unopposed, will do less to supplement 
our efforts than its more obliging though feebler fellow 
under similar circumstances. This apparent paradox is 
explained by our recognising that when the external 
rectus has been divided, the superior and inferior obliques 
together retain a considerable amount of abducting power, 
so that the adductors are not left unopposed ; when the 
internal rectus has been tenotomised the superior and in- 
ferior rectus in the same way still oppose the abductors 
somewhat, but have less power than the obliques in the 
first case. In other words, the superior and inferior 
obliques together contribute more to abduction than the 
superior and inferior recti to adduction of the globe. This 
a priori is likely if the work done in the two movements 
be the same, considering that the pure abductor is a 
smaller muscle acting at less mechanical advantage than 
the pure adductor. 

If we look also at the angles at which the obliques and 
superior and inferior recti approach the globe, the idea is 
further supported. In Diagram I (vide infra), AB repre- 
sents the line of the superior and inferior recti making an 
angle a with the sagittal axis ; CD the line of the obliques 
making an angle /3, with the same axis of an emmetropic 
eye. Berry gives the angle a as 27°, (B as 51°; according 
to Swanzy, a = 20°, f3 = 55°; whilst E. Fuchs gives 23° 
as the measurement of a. The angles support the view 
that the obliques aid abduction more than the superior 
and interior recti aid adduction; they prove nothing of 



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452 CONCOMITANT STRABISMUS. 

course, without an accurate knowledge of the power of 
the respective muscles and the mechanical advantage as 
regards distance from the centre of rotation at which 
they get their attachment to the globe. On the question 
of relative power for lateral movement, the angles shown 
in Diagram I are suggestive but not conclusive. I have 
introduced the diagram with the object of extending its 
application to myopic and hypermetropic eyes. Let us 
consider myopia first. 

E. Fuchs, in his generally accepted measurements of 
eyes and their muscular attachments (Von Graefe's 
Archives, xxx, 4, p. 1), states that in myopia the recti 
muscles are inserted at distances from the scleroccrneal 
junction not greater than in the normal eye, and we 
must assume, therefore, that the elongation of the globe 
does not affect this part of the eye, although it is 
enlarged in circumference here ; the posterior part of the 
eyeball is the part where especially the elongation takes 
place which leads to axial myopia ; this results, according 
to Fuchs, in the oblique muscles being attached at points 
slightly farther from the posterior pole, though certainly 
not nearer the centre of lateral rotatory movement, possi- 
bly farther from this point. It is well known that myopic 
eyes are usually prominent ; the posterior pole supported 
on the retro-ocular tissues will be on the same transverse 
vertical plane as the emmetropic or hypermetropic eye, 
and the globe in elongating becomes more prominent 
anteriorly; this will result, I suggest, in the oblique 
muscles passing more transversely to their insertion and 
less antero-posteriorly (Diagram II). In other words, the 
angle /3 is increased ; the angle a is at the same time 
reduced, for the rectus superior and rectus inferior pass 
Jess obliquely forward, having a greater distance in which 
to arrive at their insertion on the globe whose lateral 
position with regard to the antero-posterior mid-vertical 
plane of the orbit is not altered. The increase of the 
angle /3 seems to me to accord well with Fuchs's observa- 



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CONCOMITANT STRABISMUS. 



4r5l 



tion that the line of insertion of the superior oblique 
(shown by the dotted line in the diagrams) in myopic 
eyes is almost constantly more anteroposterior than in 
emmetropic or hypermetropic eyes; it is also usually con- 




Diaeram I. 



II. 



III. 



fined to the postero-external quadrant of the globe, its 
posterior end terminating on the outer side of the vertical 
meridian of the globe and not transgressing it as in the 
type of insertion which he regards as typical of hyper- 
metropic and emmetropic eyes. The result of the altera- 
tion in the angles of approach of the tendons would 
result in the abducting power of the oblique muscles 
being increased in myopia, while the adducting power of 
the superior and inferior recti would be diminished. In 
myopia the balance of power is disturbed in favour of the 
abductors; slight though the advantage gained may be, 
the total power required to rotate the globe is very small ; 
parallelism now can only be obtained and maintained by 
volitional impulses constantly imparted to the adductors, 
and if the incentive to these be diminished by failure of 
one eye to contribute a practical share to binocular 



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^ CONCOMITANT STRABISMUS. 

vision, the impulses will not be sent to the adductors, the 
position of rest will be assumed, i.e. 9 a divergent stra? 
bismus will result. 

In the hypermetropip eye, its posterior pole being 04 
the same plane as that of the myopic or of the normal 
eye, and the globe being small, the superior and inferior 
rectus would have to pass outwards more abruptly in 
their course forwards to their insertion ; the obliques will 
have a slightly longer distance in which to pass back to 
their insertion, and their direction will therefore be a 
trifle more antero-posterior and less transverse. In hyper- 
metropia the angle a is increased, and the angle is 
diminished (Diagram III). The balance of power is dis- 
turbed in favour ol the adductors ; this, supplemented by 
the association of convergence with the necessity to use 
the accommodation, will result in convergent strabismus 
as the position of rest, and more probably so if one eye be 
deficient. 

When abduction is once started, the obliques are 
placed in a more favourable and steadily improving posi- 
tion to abduct, while the adduction power of the superior 
and inferior recti diminishes as the axis of the globe 
comes to lie nearer and nearer to their own axis; as the 
globe is adclucted, the superior and inferior recti gain in 
power of contributing to this movement, which the 
obliques can oppose at less and less advantage. 

I would suggest then that we recognise more, fully 
the combined action of every extra-ocular muscle in 
effecting even the most simple movement. That we 
cease altogether to speak of insufficiency of the internal 
recti. As a cause of divergence, let us substitute pre- 
dominance of the abductors, and distinguish that condi- 
tion from insufficiency of the adductors, a term which we 
may employ to denote the inability to maintain active 
convergence; predominance of the adductors will be a 
factor m causing concomitant convergent strabismus. In 
using these terms, let us remember that when one group 



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CONCOMITANT STRABISMUS. 455 

of muscles is predominant, the term is a relative one, and 
implies that at the same time its antagonistic group of 
muscles is placed at a mechanical disadvantage. Used 
with this reservation, passive predominance of one group 
of muscles will tend to a new position of rest, either of 
convergence or of divergence; the strabismus is the 
result of the new balance of power which has been struck 
between the adductors and the abductors. 



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456 

NOTES ON GLIOMA RETINA. 

By C. Devereux Marshall, Curator. 

The cases reported in this paper are those which have 
occurred at Moorfields since the year 1890, when an article 
on the subject appeared in the Reports by Messrs. Lawford 
and Collins, with a record of 60 cases. In addition to 
those which were actually treated in the hospital, a few 
cases have also been obtained from private sources, but 
in all of them the eye containing the growth has been 
pathologically examined after removal. Mr. Tweedy has 
sent two eyes from the same patient, while Mr. J. H. 
Fisher, Assistant Ophthalmic Surgeon of St. Thomas's 
Hospital, Mr. Rockliffe, of Hull, and Mr. Horsey, of Ottawa, 
have sent one each. 

Several cases have been excluded in which there 
appeared to be some doubt as to the nature of the growth, 
and in one or two instances an eye has been received but 
Avith insufficient notes to enable one to make use of it for 
present purposes. 

This paper is arranged on lines very similar to the one 
which preceded it, and, as it has been compiled chiefly as 
a clinical record rather than as an article dealing with 
glioma generally, it will be impossible to treat of many of 
the interesting questions which the study of this disease 
brings forward. 

The chief literature on the subject up till 1890 has 
been carefully recorded in the previous paper, conse- 
quently it will not again be referred to here unless it be 
required to assist in bringing out any other facts. The 
whole subject has, moreover, been treated in a most 
complete manner in a book published this year by Hugo 
Wintersteiner, " Das Neuroepithelioma Retinas." 

Since 1890 there have been 32 undoubted cases of 
glioma retinas, which have been examined in the labora- 



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ON GLIOMA RETINJE. 457 

tory, and this represents a total of 37 eyes, as there were 
five cases in which both eyes were removed for growth, 
either together or after a certain interval of time had 
elapsed. 

Sex. — These cases show that they are distributed fairly 
equally between the two sexes. Of the 32 cases, 15 
were males and 17 females. This shows a slight pre- 
ponderance of females, but as a rule it is found that in 
a large number of cases there is but little difference as to' 
the liability of either sex to the disease. 

Among 193 cases collected by Lawford and Collins 
there were 95 males to 78 females, but there were also 
20 in which the sex was not mentioned. 

Eye Affected. — It is well known clinically how fre- 
quently cases of glioma are seen in which both eyes are 
affected, and it is always of the greatest importance to 
examine the eye which is apparently sound as well as that 
which is known to be affected. 

In this series both eyes were affected in 12 cases, six 
of them had the two eyes removed, which were after- 
wards examined pathologically (Nos. 62, 63 ; 65, 67,* 71, 
92). 

The remaining eyes were removed elsewhere in two 
cases, and consequently were not obtained for further 
examination (Nos. 61, 70), while in the other four (Nos. 
76, 84, 88, 89) the second eye was not removed. 

Of the uni ocular cases, 10 affected the right eye only 
(Nos. 64, 66, 68, 72, 74, 79, 81, 82, 85, 86). Nine affected 
the left eye only (Nos. 69, 73, 75, 77, 78, 80, 83, 87, 91), 
while in one case (No. 90) it is not stated. 

Age at which the Growth became apparent. — It is fre- 
quently a very difficult question to decide how long a 
glioma has been present within an eye. 

Judging from the number of cases which are seen 
during the first few months after birth, in which the 
growth has attained a very large size so as frequently at 

* For report of the first eye, see previous piper, Case No. 50. 



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458 ON GLIOMA RET1NJE. 

this early age to entirely fill the eyeball, it is certain that 
they must really have been present at birth, and had 
probably been growing during a considerable portion of 
intrauterine life. 

Their presence is, however, not as a rule recognised 
until they have become sufficiently large to be seen by 
the mother or nurse through the undilatecl pupil. 

The earliest age at which any of these cases were seen 
was one month after birth, and this happened in Nos. 79 
and 84. 

The total number of eyes which were found to con- 
tain gliomata before the children reached the end of the 
first year of life was 15, and these represented 11 patients. 
Nos. 61, 76, 79, 83, 84, 87, 92 all had the first eye 
affected. Nos, 62, 63, 70, 71 had both eyes affected. 

Between the ages of one and two years 12 eyes were 
found to be affected, representing nine patients. Nos. 69, 
75, 77, 85 had the first eye affected; Nos. 61 and 76 had 
the second eye affected ; while Nos. 65, 88, 89 had both 
eyes affected. 

Between the ages of two and three years there were 
eight eyes affected, from eight patients. Nos. 61, 68, 72, 
73, 74, 84, 91 all had the first eye affected, while No. 92 
had the second eye affected. 

Between the ages of three and four years there were 
four eyes affected from four patients. Nos. 80, 82, and 
86, all had the first eye affected, while No. 67 had the 
second eye affected. 

Between the fourth and fifth years there were two 
eyes affected, from two patients, both of them being the 
first eye Nos. 64 and 78. 

No cases were recorded occurring between the fifth 
and sixth years. 

One patient in this series was 6 years and 10 months 
old when the eye was first seen to be affected ; this was 
N T o. 81. 

In one case, No. 90, the age is not recorded. 



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ON" GLIOMA RETINiE. 459 

The following is a summary of the ages at which the 
presence of the tumour was detected. 

Before the 1st year 15 =■ 34'89 per cent. 

Between the 1st and 2nd years 12 = 27'90 „ 

2nd and 3rd „ 

„ 3rd and 4th „ 

,, 4th and 5th ,, 

,, 5th and 6th ,, 

,, 6th and 7th „ 



Unknown. 



8 


= 


18-60 


4 


= 


9-30 


2 


= 


4-65 





= 


— 


1 


= 


2-32 


1 


= 


2-32 



43 99-98 

In only two eases was the growth noticed as early as 
the first month. In one of them (No. 79) the eye was not 
removed for over two years; by that time the optic nerve 
was much involved, and there can be but little doubt 
that the disease in so advanced a stage ultimately proved 
fatal, but unfortunately no information could be obtained 
after the child left the hospital. 

In the other case (No. 84) the eye was removed when 
the child was two months old, and he remained in good 
health for two years and eight months ; he saw well with 
the other eye, and was bright and intelligent. On examin- 
ation, however, at this date a large gliomatous tumour was 
seen at the upper and inner part of the retina. The parents 
refused to allow the other eye to be removed, but at pre- 
sent sufficient time has not elapsed for the growth to have 
made any very marked change either in the external 
appearance of the eye or in the general health of the 
child. There is no local recurrence in the orbit, nor any 
evidence of central disease. The growth in the second 
eye is of course absolutely independent from that of the 
first. 

The table above illustrates the fact that the growths 
became apparent during the first two years of life in 60 
per cent, of these cases, while in about 80 per cent, it 
appeared during the first three years. It is extremely 



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4 GO ON GLIOMA RETIME. 

uncommon after this. In one case only did it occur as late 
as the seventh year. 

Hirschberg has recorded a case in which the growth 
was first noticed in a child aged 11 years, but it is exces- 
sively rare to find such a development at so late a period. 

Recoveries. — A case having been recorded by Vetsch, 
in which a child died of recurrence three years after the 
removal of the affected eye, one cannot look upon a 
patient as being permanently cured until at least this 
length of time has elapsed, although in by far the ma- 
jority of cases the growth, unless it has been permanently 
removed, has reappeared long before this. 

There is, however, in this series one case which looks 
as if this period of time would have to be lengthened ; 
this is No. 69, where the child was first noticed to have 
an affection of the left eye when 12 months old. The eye 
was not removed until three years later, when the exam- 
ination proved that a glioma was present. 

The) operation was performed in October, 1892, and the 
patient remained in good health until October, 1897. The 
child is now very ill, and is said, by the surgeon under 
whose care he is, to be suffering from " a recurrence of the 
growth on the brain." This, however, cannot at present 
be proved. 

If, however, we accept the three years' limit as indi- 
cating the time after which the patient may be considered 
safe from recurrence, we find that there are 13 children 
who are alive and in good health at the present time, and 
who may be considered cured, and these cases include 
five in which both eyes have been removed, Nos. 62, 63, 
65, 67, 70, and nine in which only one eye was removed, 
Nos. 64, 6Q, 68, 72, 73, 74, 75, 81, 82. 

Of the remaining cases, six are known to be dead, Nos. 
70, 76, 80, 88, 89, 90, while one, No. 61, was suffering from 
recurrence in the orbit and elsewhere when last heard of, 
three years ago, and is almost certainly dead by this time, 
but the parents went to South Africa and cannot be traced. 



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ON GLIOMA RETINiE. 



4(51 



There are five eases which have not been heard of 
since they left the hospital, they are Nos. 75, 77, 79, 83, 
87. In Case 84, 2 years and 8 months had elapsed without 
there being any local or general recurrence, but on exami- 
nation a glioma was found in the other eye. In Case 91 
a recurrence was present in the orbit, and the child is 
probably now dead. 

In the remaining three cases, Nos. 85, 86, and 92, 
sufficient time had not elapsed to say whether they were 
cured or not, and in Case 92 both eyes had been removed. 

The following gives the length of time which has 
elapsed since the operation in all the cases still alive, and 
which show no sign of recurrence : — 



Oases which have 

exceeded the 
three years' limit. 



Cases in which less 

than three years 

have elapsed since 

excision. 



No. of No. of years 

case. since excision. 

"62 6^ 

63 6^ 

64 6 T \ 

65 6 T \ 

66 6 T \ 

67 6 

68 5 T 9 T 

71 5 T V 

72 . 5 

73 4 A - 

74 4 T \ 

78 3-fr 

81 3 T V 

82 3 T % 

'85 2-A- 

86 2 T V 

92 T 7 T since first eye was 

removed. 



Duration of Life in Fatal Cases. 

Sis eases are known to have terminated fatally, ISTos. 70, 76, 
80, R8, 89, 90: — 



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462 ON GLIOMA RETINAE. 

Years affcpr 
excision. 
No. 70 terminated fatally when child was 2(f this being 2^ 
76 l * 9 

55 ^^ n 55 55 ^12 55 T~3 

55 83 ,5 „ „ 2A „ tV 

55 89 „ ., „ 2 „■ Y \ 

90 K s 2 

55 ^^ 55 5} 55 ^T2 55 TT 

Interval of time between Discovery of the Growth and 
Operation in Fatal Cases and Cases of Recovery, 

Of 15 case's which are included in the list of recoveries 
the average time which elapsed between the discovery of 
the growth and the excision was 3*06 months, while in 
four fatal cases the average interval was 4*77 months. 
The difference of time was much greater in the cases 
recorded by Lawford and Collins, being in the former 
4 months and in the latter 14 months. 

! Site of Recurrent Growth, 

Out of seven cases, of which five were fatal, and two 
were probably fatal, there was a local recurrence in five 
(Nos. 70, 80, 88, 90, 91). 

In three cases there was recurrence in both orbit and 
brain (Nos. 70, 88, 91), while in one there' was an intra- 
cranial growth only (No. 89), and one child was stated, 
when last heard of, to be suffering from u internal 
tumours" (No. 61). 

On the Shrinking of Eyes which are Affected with Glioma, 

Although several cases have been recorded in which a 
shrunken eye probably contained a glioma, yet in all of them 
there has been some link wanting in the chain of evidence. 

In the paper by Lawford and Collins two cases are 
recorded in which there is some evidence that the shrink- 
ing eyes contained gliomata (Nos. 36 and 58), yet they 
were not proved. 



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ON GLIOMA RETlNiS. 403 

As in one of the cases here recorded (No. 71) both 
eyes have been examined microscopically, one of which 
" was much shrunken, it is thought desirable to publish the 
notes in detail 

Ellen T., ask 4 months, was admitted under Mr. Couper on 
November 21, 1892, with the following history : — 

" Two weeks ago a white speck was noticed behind the left 
pupil, but since the child was a month old the eye has been 
4 turned in.' The child is otherwise healthy, and has had no 
severe illness. There are two other children, aged respectively 
4 and 2 years, and these are quite healthy. There is no history 
of any hereditary disease, nor of any affection of the nervous 
system in the family." 

On November 22, 1892, the eye was removed. T. normal. 
At the same time the right pupil was dilated with atropine and 
the eye thoroughly examined, but no suspicion of a growth was 
seen. 

After hardening in Miiller's fluid, the excised ej^e was 
bisected and the following condition noted : — 

" At the posterior part of the globe, starting from the retina, 
probably its outer surface, is an oval- shaped mass of a yellowish 
colour and soft consistency • it comes forwards to about the 
centre of the vitreous, and is situated over the optic nerve, 
which, however, appears not to be involved." 

One half of the eye was embedded in celloidin, and the 
following description is given of the microscopic appearance : — 

u The growth presents the typical appearance of a glioma 
retinas. There are numerous round cells infiltrating the optic 
nerve up to its point of section; it is difficult to say if these 
are of inflammatory origin, or if they are really glioma cells. 5 ' 

Six weeks later, January, 1893, the child was again brought 
to the hospital, and a white gliomatous mass was then seen in 
the right fundus. 

In September, 189-1, 1 year and 10 months after the excision, 
the following note was made: — "Child seen, and is in good 
health ; the right eye is affected, apparently with glioma 
endophytum ; there are floating masses in the vitreous," 

In September, 1895, " Nodules of growth and blood vessels 
are seen immediately behind the lens in the right eye." 
VOL, X1Y. 2 H 



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464 ON GLIOMA FvETINTE. 

In November, 1896, a letter was received from Dr. McFarland, 
which stated that the child had recently liad a feverish attack, 
with excessive pain in the head. The eye was very much 
shrunken, bat no discharge. The mother states that the 
general health is now good. 

In September, 1897, the child was again seen, and the fol- 
lowing note made : — " The right eye is quite blind, irritable, 
injected, shrunken, and completely atrophied. T. —3. The 
cornea is hazy, but contains no evidence of having been per- 
forated ; there is a small transverse calcareous film across it ; 
nothing deeper is visible." 

The eye was removed, and hardened in formol. 
On Section. — " The cornea is at least double its proper thick- 
ness, and the iris and remains of the lens are in contact with 
it, thus entirely obliterating the anterior chamber. 

" The lens is dislocated slightly downwards, and has for the 
most part disappeared ; the capsule is, however, calcareous, and 
the space within it contains hardly any of the original lens. 

" The vitreous is entirely absent, its place being taken by a 
solid, whitish growth of a rather dense consistence. The retina 
is unrecognisable, but the choroid and sclerotic are much 
thickened." 

Microscopic "Examination. — " The tumour is a small, round 
cell growth, containing large vascular spaces. Nearly all the 
cells stain well, and there is remarkably little degeneration. 
The ciliary body and the whole of the uveal tract is involved in 
the growth, the former structure being so much destroyed that 
it is hardly recognisable, while the choroid is greatly thickened 
at some places, and much atrophied at others." 

" In the vicinity of the choroid numerous pigment cells are 
seen in the growth, and in places tumour cells are seen invad- 
ing the choroid secondarily. The optic nerve is extensively in- 
volved. In addition to the ordinary glioma cells, there are a large 
number of others present of a very different appearance. They 
are much smaller, and they mostly contain two or more nuclei, 
which stain deeply with hematoxylin, while the protoplasm takes 
up the eosin stain very readily ; others show marked signs of 
degeneration. These cells are scattered all over the section, 
but at jDlaces are collected together in masses by themsclvos, 



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ON GLIOMA RETINiE, 465 

" The growth has all the ajypearance of being a glioma, and 
the eye has probably become atrophied by the destruction of the 
ciliary body, and by the extensive involvment of the whole of 
the uveal tract." 

This case is the most complete one with which I am 
acquainted, and it proves beyond doubt that an eye which 
contains a glioma may undergo atrophy, leading to shrink- 
ing of the whole globe. 

There was nothing to lead one to suppose that the 
eye had ever been perforated. The cornea certainly had 
not been, and there was no sign of the tumour extending 
outside the sclerotic, although the optic nerve was much 
affected. 

Family History. 

The question as to whether glioma is likely to appear 
in more than one member of the same family is of the 
utmost importance to the anxious parents who have, 
perhaps, lost a child from this dreaded disease. 

That such an occurrence must be very uncommon, at 
least in England, is proved by the remarks in the previous 
paper by Lawforcl and Collins, where it is stated, u we 
have found no instance in which more than one member 
of the family has suffered from glioma of the retina." 

Fuchs* records a case in which a child, set. 4 years, was 
brought to him suffering from a glioma of the right eye, 
which had already perforated the sclerotic. The entire 
orbital contents were removed, but the child died six 
months later, with brain symptoms and a local recurrence. 

Some months later a brother of the last patient was 
brought, who was 2 years old, and whose right eye had 
been blind since birth, although it had only recently 
become enlarged. This child likewise had glioma, and 
died of a recurrence about a year after removal of the 
eye and tumour. 

Soon afterwards the mother brought her last child, 

* Text-book of Ophthalmology, p. 418. 

2 H 2 



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A66 OJN GLIOMA RETINiE. 

then only a few months old, because she had noticed a 
peculiar appearance in the left eye. 



This child, however, did not have a glioma, but 



a 



typical coloboma of the iris and choroid. The family 
history here is taken to indicate that " a congenital 
morbid disposition very often lies at the bottom of glioma." 
One of the cases (No. 89) has a most interesting 
family history, and as such a case has not previously 
come under observation, the full details will be given. 

Ca.se 89. — Ada Lydia W , set. 2 years, was admitted 

under Mr. Lang on July 16, 1896, with the history that for 
about two months a whitish appearance had been seen in the 
right eye. Glioma was diagnosed, and the eye was excised. 
On examination under chloroform a glioma was also seen in the 
left eye. Consent for the removal of this, however, couJdnot be 
obtained. She was not again seen, and for about seven or eight 
months she remained fairly well, but at the end of that time 
she suddenly died in convulsions. The parents, who were most 
illiterate, olid not notice any change in the remaining eye. 

The history of this family, although perhaps a little incom- 
plete in detail, is extremely interesting. 

The first child the parents had was a girl, born in 1879. 
When about 2 years of age a white mass was seen inside the 
eye, and she was seen at more than one London hospital, but 
still no operation was performed. She became worse, until at 
last the eye burst, and she died in convulsions, set. 3| years. 

The second child was a boy, whose eyes were not known to 
be affected, but he died in convulsions, set. 3 months. 

The third child was a boy, who at the present time is 15 
years of age. The right eye became first affected when he was 
about 9 months old ; it was similar in appearance to that of the 
first child. He was taken to Guy's Hospital, where the eye 
was removed. He now has good sight in the remaining eye, 
and is in excellent health. 

The fourth child is a girl, set. 9 years, who has no eye 
affection, and is in good health. 

The fifth child is 7 years of age, and is also in good health, 
with no eye affection. 



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ON GLIOMA RETINA. 467 

The sixth child is the patient who undoubtedly had glioma? ■ 
which directly or indirectly proved fatal. 

There is nothing of note in the history of the father's or 
mother's family, and there is no consanguinity. 

In the face of the numerous cases in which only one 
member of the same family is affected with glioma, we 
must conclude that such a remarkable fact that three 
members of one family have probably suffered from the 
disease is a thing of very great rarity, but still the fact 
that such a thing may occur should make us very guarded 
in giving a prognosis with regard to other children which 
the parents may possibly have. 

Undoubtedly the correct thing to do would be to 
examine at intervals these children, so that the presence 
of a glioma should be detected at the earliest possible 
period, as it is a fact which is proved beyond all ques- 
tion that the sooner an eye affected in this way is 
removed the better will be the chance of jthe life of the 
patient. 

There is one other fact which appears by some to be 
hardly realised, viz., that however completely the growth 
may have been removed, and no matter how healthy the 
optic nerve is at the point of section, y,et the factor 
which determined the growth of a glioma in one eye may 
still be present in the other in a latent form, anrl in such 
a case it would be impossible, or at any rate most unwise, 
to state that the child was free from all source of disease 
until such time has elapsed beyond which glioma has 
never been known to appear. Case 84 is an example of a 
child remaining to all appearance quite healthy for a 
period of two years and ten months after an eye contain- 
ing the growth had been removed. The parents noticed 
nothing wrong with the child nor with the sight, and the 
mother brought him to be examined only because she had 
received a letter requesting her to do so. She came 
expecting to be told that nothing was the matter, but on 
examining the patient a fairly large glioma was seen to be 



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4G8 



ON GLIOMA RETINiE. 



present at the upper and outer part of the eye, and being 
out of the direct line of vision it was unnoticed. Indeed, 
such cases are by no means rare. 

A case has recently been observed which leads one to 
impress strongly the fact that it is impossible to give too 
guarded a prognosis in cases of this disease, the origin of 
which is so obscure, and although everything points to the 
fact that the tumour has not exceeded its ocular bounds, 
one should not state that the disease is entirely eradicated 
by the operation ; time only can prove this. 

Cases of Glioma Retinje. 



No. of 
case and 
.Register 

No. 



61 
3309 



f 62 
3345 



^ 3365 



f 63 
3369 



33-J9 



64 
341S 



Name, Surgeon, 
and date. 



Violet Morris 
A. Q, S. 
19,1.91 



Hilda Leyerett 
W. L. 
2.3.91 



17.3.91 



"William Holyoak 

a. L. 

20.3.91 



a. l. 

20.3.91 

Helen Holbrow 
J. C. 
2.6.91 



Eye 

affected. 



R. 



R. 



As;e when 
growth, 
was first 
noticed. 



Age at 

date of 

operation. 



Date of 1st 
symptom of 
recurrence. 



Duration of 
life after 
operation. 



Alive 



Hosted by GOOgle 



ON GLIOMA RETIN7E. 



4()9 



Great suffering may be caused to a family, and severe 
criticism may be incurred by the surgeon should a child 
ultimately suffer from a local or general recurrence, or 
should an independent tumour start in the remaining eye, 
after a positive assurance has been given that the patient 
is completely cured. 

In conclusion, I have to thank Dr. Gordon Byers, the 
Junior House Surgeon at Moorfields, for his assistance in 
helping me to trace the cases which have formed the basis 
of this paper. 



Cases of Glioma Retina. 



Position and extent 
of primary growth- 



Globe about frds full of 
growth, which arises 
from outer surface of 
retina 



£ths of globe filled with 
soft growth from outer 
surface of retina 

Nodulated growth 

springing from outer 
surface of retina 

Glioma endophytum. 
Retina extensively in- 
volved. Yitreoue cavity 
almost full 

Glioma exophy turn half 
filling globe 



Glioma endophytum. 
Retina extensively in- 
volved 



Tension. 



T, n. 



T.+ 



Site of 
recurrence. 



1 Internal tu- 
mours " 



None 



Family history. 



Negative 



Remarks. 



R. eye excised in 1892 
elsewhere for glioma. 
She then had recur- 
rence in orbit, and is 
almost certainly dead 
now. Cannot be traced. 

In excellent health, Sep- 
tember, 1897. 



October, 1897, alive, but 
an idiot. 



In good nealih, Novem- 
ber, 1897. 



Hosted by G00gle 



470 



ON GLIOMA RETINZE. , 
Cases of Glioma Rutins. 



No. of 
ease and 
Register 

No. 



f 65 
! 3420 



^ 3420 

66 
3421 



67 
3601 



68 
3651 



69 
3825 



70 
3834 



f 71 
3862 



t 5319 

72 
3898 



Fame, Surgeon, 
and date. 



Victor Allen 
W. L. 
4.6.91 



Walter Sear 

A.S. M. 

5.6.91 

Sidney Rabbitt 
E. N. 
20.1.92 



\ 

Minnie Solomons 

E/K 

12 3.92 

Sidney Richardson 
W. L. 
10.10.92 



John Keeble 

J. T. 

25.10.92 



Ellen True 

J. C. and E. T. C. 

22.11.92 



25.10.97 

Annie Cope 
A. S. M. 
13.L 93 



Eye 
affected. 



R. 

L. 
R, 



R. 
R. 



Age when 
growth 
was first 
noticed. 



2 H 



3 tV 



Age at 

date of 

operation. 



2A 



3t% 



3A 



2t% 



Date of 1st 
symptom of 
recurrence. 



Unknown . . 



Duration of 

life after 

operation. 



Alive 



Alive 



Jsted by G00gle 



OX GLTOMA RETIN.TC. 
Cases op Glioma Retire. 



471 



Position and extent 
of primary growth. 


Tension. 


Site of 
recurrence. 


Family history. 


Remarks. 


(ihoma exophytum 
Whole retina involved 
and detached 


T. full 


None . . 


Negative . . 


November, 181 » 7, in good 
heal tli. No sign of re- 
currence. 


Shrunken globe contain- 
ing a glioma 


Shrun- 
ken 


<* 


„ •• 


JJ >> )J 


Growth, from outer sur- 
face of retina. Numer- 
ous nodular masses 


T. +1 




,, . . 


October, 1897, alive, and 
In good health. 


Growth from inner sur- 
face of retina not in- 
volving 0. D. 


T.n. 






The R. eye was removed 
Jan uar v, ] 889 . Ca se 
No. 50 in previous paper 
by Lawford and Col- 
lins. In October, 1S97 ; 
the child is alive and 
in excellent health. 


Flocculent growth from 
inner surface of re- 
tina. 0. N. unaffected 


T.n. 


„ .. 


» ' ' 


September, 1897, alive 
and well. 


Growth, from outer sur- 
face of detached re- 
tina. 0. N. invaded, 
but not so far back as 
section 


T. + 


>> 


Not known 


November, 1897, ex- 
tremely ill, is delirious, 
and has convulsions. 


Growth from outer sur- 
face of retina 




Intracranial 
and right or- 
bit 


Several children of 
parents have died 
from " consump- 
tion of the bow- 
els." 


R. eye seen to be affected 
at time left was re- 
moved. The right eye 
was removed elsewhere 
one month before child 
died. 


Soft growth filling half 
the vitreous growing 
from outer surface of 
retina. O.N. invaded by 
round cells, ? growth 




None 


Negative. 


G-lobe half full of growth 
from outer surface of 
retina. O.N. involved, 
but not so far back as 
section 


•• 


None c , 


„ .. 


September, 1897, patient 
in excellent hen 1th, 
with no sign of recur- 
rence. 



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472 



ON GLIOMA RETINiE. 
Cases op Glioma Retinae. 



No. of 
case and 
Register 

No. 


Name, Surgeon, 
and date. 


Eye 
affected. 


Age when 
growth 
was first 
noticed. 


Age at 

date of 

operation. 


Date of 1st 
symptom of 
recurrence. 


Duration of 
life after 
operation. 


73 

4001 


William Scannell 

A. Q. S. 

4.5.93 


L. 


2« 


3 




Alive 


74 
4111 


Harry Chattaway 
W. T 
5.10.93 


R. 


2 


2t% 




„ 


75 
4120 


Florence Best 
A. S. M. 
10.10.93 


L. 


1 


1A 


•• 


Unknown . . 


76 
4124 


Louisa Kablean 

W. T. 

16.10.93 


L. 



1'2 


7 ■ 
1 2 


Unknown . . 


9 
1 2 


77 
42j6 


i 

Mabel Bridle 
J. B. L. 

Case from St. 

Thomas's Hospital 

11.5.94 


L. 


1 


2 


•• 


Unknown . . 


78 
4362 


Gi-eorge Sargent 
A. S. M. 
13.7.94 


L. 


4 


4 


None 


Alive 


79 
4372 


Arthur Sims 
J. T. 

17.7.94 


R. 


i 

1 2 


2iV 


•• 


Unknown . . 


80 
4381 


James Armstrong 

Mr. Horsey's case 

18.4.94 


L. 


3-°- 


4 


4 months 
after opera- 
tion. 


9 
1 2 


81 
4393 


Gilbert White 

J. B. L. 

8.8.94 


R. 


&t% 


7 




Alive 


82 
4399 


Helen Warner 

J. T. 

17.8.94 


R, 


3 


3 




» • • 



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ON GLIOMA RETINA, 
Cases of Glioma Retinae. 



473 



Position and extent 
of primary growth. 

Vhole inner surface of 
retina involved and de- 
tached. O. N. not in- 
volved 

3oth surfaces of retina 
involved in a glioma- 
tous growth 

jarge growth from inner 
surface of retina 



r locculent growth from 
outer surface of retina, 
nearly filling globe 



Vitreous chamber filled 
w T ith new growth 



jarge growth springing 
from detached retina 



^locculent growth from 
inner surface of retina ; 
optic nerve much in- 
volved 

Hobe nearly full of 
growth ; O. N. exten- 
sively involved 

'mall growth from 
outer surface of retina, 
which is completely 
detached ; O. N. not 
affected 

r itreous chamber al- 
most full of growth ; 
O. N. much involved 



Tension. 


T. 


full 


T 


n. 


T 


n. 


i 1 


n. 


T 


n. 


T. 


n. 


T. 


+ 2 


T 


n. 


T. 


+ 1 




None 



Unknown 



Unknown 



Orbit , 



None 



Family history. 



Negative . . 



Only child 



8th month child.. 



1st child 



Negative 



Negative. 5th 

child. All the 
others healthy. 



Remarks. 



September, 1897, in ex- 
cellent health. 



September, 1897, in ex- 
cellent health. 



Patient has not been 
heard of since leaving 
hospital. 

Two months before 
death other eye was 
found to contain a 
growth -, a month later 
recurrence in L. orbit, 
nu'merous lumps at 
ba'ck of head. Child 
died in a fit. 



November, 1897, in 
good health. R. eye 
healthy. No recur- 
rence. 

Not heard of since 
operation. 



November, 1897, child 
is now in good health, 
but has had an attack 
of interstitial keiatitis 
in left eye. 

September, 1S97, in 
good health. No recur- 
rence. 



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474 



No. of 
case and 
Register 

No. . 



83 
4495 



84 
4528 



S5 
4672 



86 
4757 



87 
4827 



88 
4848 



89 
4959 



ON GLIOMA RETINZE. 
Cases of Glioma Retinae. 



Name, Surgeon, 
and date. 



Bertie Aylen 
R. M. G-. 
19.12.94 

Sidney Everist 
E. N. 
9.2.95 

Leonard Carter 
A. Q,. S. 
12.8.95 

Elsie Burdett 
J. B. L. 
27.11.95 

James Rooke 
J. B. L. 
12.2.96 

Nellie' Norfolk 
E. N. 
11.3.96 



Ada Wright 
W. L. 
16.7.96 



Eye 

affected. 



L. 



R. 



R. 



R, 



Age when 
growth 
was first 
noticed. 



1* 



Hf 



lit 



Age at 

date of 

operation. 



I- 4 - 

J -\-z 



2A 



Bate of 1st 
symptom of 
recurrence. 



Duration of 
life after 
operation. 



Unknown. 



Ali- 



Grrowth pre- 
sent in or- 
bit when 
eye was ex- 
cised 



Unknown 



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I 



ON GLIOMA RETINZE. 
Cases of Glioma Retina. 



475 



Position and extent 
oi primary growth. 


Tension. 


Site of 
recurrence. 


Family history. 


Remarks. 


Vitreous frds full of 


T. +2 


None . . 




Not heard of since opera- 


growth 








tion. 


Vitreous nearly half 


T.n. 


R. eye affected 




October, 1897, child 


full of growth, and 




with glioma 




in good health, but a 


almost entirely de- 








glioma seen to be pre- 


tached 








sent in R. eye. 


|ths of globe full of 


T. + 


None . . 


, , 


October, 1897, child in 


growth ; retina com- 








excellent health. L. 


pletely detached 








eye healthy. 


Growth springs from 


T. + 


, , 


Negative . , 


December, 1897, in good 


outer surface of re- 








health; no recurrence. 


tina; it about half 








L. eye healthy. 


fills globe 










Large white tumour 


T.n. 






Not heard of since opera- 


growing from retina, 








tion. 


■which is quite de- 










tached 










Grlioma completely fill- 


.. 


Local, and 


Specific history 


R. eye blind before 


ing eyeball and part 




probably in 




death. Grlioma seen at 


of orbit at the back 




brain 




time of operation. 


Large growth from cho- 


T.n. 


Probably in 


First child, a girl, 


Child died in convul- 


roidal surface of re- 




brain 


died in convul- 


sions. 


tina 






sions, set. Sh ; 
white mass seen 
in eye. It was 
not removed 

Second child, a 
boy, died in con- 
vulsions, set. 3 
months. No 
known eye affec- 
tion. 

Third child now 
set. 15. R. eye 
removed for 
glioma when 10 
months old. 
Nov. (1897) in 
good health. 

Fourth and fifth 
children, set. 9 & 
7, in good health. 

Sixth child is the 
patient. No spe- 
cific history and 
no consanguinity. 


Grlioma seen in left eye 
at time that R. was ex- 
cised. 



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476 



ON GLIOMA RETINiE. 
Cases of Glioma Retinje. 



No. of 

case and 

Register 

No. 



90 
96 O.P. 



91 
114 O.P. 



92 
170 O.P. 



(JL90O.P. 



Name, Surgeon, 
and date. 



Dorothy Forward 

Mr. Rockliffe's cas< : 

27.3.96 



Primrose Wallace 

17.6.96 

Mr. J. H. Fisher's 

case 

Mr. T weedy' s case 
Female 
27.5.97 



Same case 
29.9.97 



Eye 

affected. 



E. 



Age when 
growth 

was first 
noticed. 



2tV 



2tV 



Age at 

date of 

operation. 



K 6 
OtoT 



2A 



H£ 



2A 



Pate of 1st 
symptom of 
recurrence. 



■^ after ope- 
ration 



Duration of 
life after 
operation. 



Hosted by GOOgle 



ON GLIOMA RETINA. 
Cases of Glioma Retime.. 



477 



Position and extent 
of primary growth. 



G-lobe nearly full of 
growth, with a large 
mass projecting into 
orbit 



Globe nearly half full 
of a dense flocculent 
growth 



Globe nearly full 'of a 
gliomatous growth. 
Head of O.N. in- 
volved, but section 
seems to be free 

Gliomatous mass filling 
nearly two -thirds of 



Tension. 



T. + 



Site of 
recurrence. 



Orbit and 

probably brain 



Orbit. 



Family history. 



Remarks. 



Child died suffering 
from sickness, head- 
ache, constipation, and 
growth in orbit. No 
P.M. allowed. 



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478 



THE OPERATIVE TREATMENT OF LAMELLAR CATARACT. 

By E. C. Fischer, late Senior House Surgeon, and 
C. Devereux Marshall, Curator. 

This is a subject "which has not for many years been in- 
vestigated at Moorfields, and as the methods of operat- 
ing have improved, it seemed to us that some interesting 
observations were to be made by examining a considerable 
number of cases. 

Many surgeons of large experience publish their results 
of the treatment of senile cataract, and a report of 1,509 
cases, which represented the operations done at Moorfields 
during five years, 1889 — 1893, was published in Vol. xiv, 
Pt. I, of these reports by one of us (C. D. M.). 

By referring to this paper a certain comparison may 
be drawn between the operations for cataract which are 
performed upon individuals who are not far removed from 
the two extremes of life. 

We may classify the operations done for lamellar 
cataracts into the following groups : — 

r (a) Simple needling. 
1,< (b) Needling followed by curette evacuation. 

L(6*) Needling followed by suction. 
2. (d) Extraction, 

It would be extremely interesting to compare these 
four operations side by side, but there is an insurmount- 
able difficulty in doing so, and we find that for practical 
purposes we can only divide the operations into two 
groups. The first includes needling either alone or 
followed by evacuation, and the second includes those 
cases in which the lens is removed as completely as 
possible, as in the case of senile cataract, without a 
previous needling. 

The reason for this is obvious. All the cases in the 



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OPERATIVE TREATMENT OP LAMELLAR CATARACT. 471) 

first group have to run the risks which attend needling, 
and whatever is done subsequent^ cannot prevent these 
indeed, many surgeons are by no means anxious to 
undertake a second operation on the eye of a child when 
the lens is undergoing gradual, if not rapid, absorption 
while the eye remains quiet and free from injection, even 
should the time be prolonged before the pupil becomes 
clear enough to render good vision possible by the aid of 
glasses. No operation can be regarded as absolutely free 
from danger* and it is often considered an unnecessary 
risk to run to undertake some further procedure when 
there is no urgent need for it. In these cases especially 
there is no great hurry. The patients as a rule are quite 
young; they frequently have sufficient vision with the 
other eye to meet their requirements, while a few months 
one way or the other makes not the least difference to 
them, a final good result being the one thing to be aimed 
at. Everyone, of course, is agreed that should there be 
anything like undue swelling of the lens leading to ten- 
sion, or even to irritation which may produce tension, it 
is wise to evacuate the lens matter before this complica- 
tion actually occurs ; in other words, no good can possibly 
result by waiting till, all the symptoms of acute glaucoma 
are present before giving relief by a further operation ; 
but should the patient be under observation one may 
safely allow the broken-up lens matter to gradually 
absorb, if it will do so without causing either pain or 
irritation. 

That a simple needling operation on any eye is un- 
attended by danger is a statement that can by no means 
be proved, and clinical experience is at direct variance 
to any such idea. 

In the paper previously referred to it was found that 
the percentage of suppuration was nearly as great after 
needling of capsule as after extraction, being 1-02 per 
cent, in the former and 1*72 per cent, in the latter, while 
the percentage of cases in which glaucomatous symptoms 
VOL. XIV. 2 I 



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480 OPERATIVE TREATMENT OF LAMELLAR CATARACT. 

set in was much greater, being 2*08 per cent, after 
needling and 0*53 per cent, after extractions of all sorts. 

Now, it becomes obvious that if after a needling opera- 
tion the eve escapes these two dangers, it has gone a 
long way on the right road towards having an ulti- 
mately successful result whatever else is done, and there- 
fore we cannot possibly compare the results of the several 
operations included in the first group. 

The cases, however, which have had a primary extrac- 
tion may be compared, as they have never undergone a 
needling operation at all. 

In the cases which form the basis of this paper there 
were 260 which were needled, or needled and evacuated, 
the exact numbers being : — 

Simple needlings , 123 

Needling, followed by curette evacuation. . 113 
Needling, followed by suction 24 



260 



Of the simple needlings, eight eyes suppurated and 
five were excised. Of the needlings followed by curette 
evacuation, one eye was excised for slow suppurative 
iritis one month after the primary operation. Of the 
needlings followed by suction, one eye suppurated and 
was excised. This gives a total of 10 lost eyes in 260 
cases, or a percentage of 3*84. Thus it is seen that 
needling in these cases yields a larger percentage of 
suppurations than needling after cataract extractions, 
which, as has previously been shown, equalled 1*02. 
It is well known that cases in which suction is per- 
formed are more liable to suppurate than when only a 
curette is used ; but the operation of suction is now but 
seldom done unless there is any great difficulty in removing 
the lens, and obviously the more instrumentation that is 
resorted to, the greater will be the risk of some complica- 
tion happening. Suction is never needed if the lens is 



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OPERATIVE TREATMENT OF LAMELLAR CATARACT. 481 

well broken up and disintegrated, as the result of the pre- 
vious needling, for in such a case it would readily come 
away without such a powerful apparatus as a suction 
syringe ; but, if it be not well disintegrated, it is better to 
leave it where it is rather than to use any forcible means 
for its evacuation. 

The cases which were extracted without a previous 
needling are so few in number that it is hardly fair to 
make a comparison. There are six of these, however, 
the notes of which are appended, so that the general 
course which such cases run may be readily seen. 

Case 1 was re-admitted with severe iritis. 

Case 3 suffered from prolapse of iris, severe irido- 
cyclitis, shrinking of the globe, and finally the eye was 
removed two months later. 

Cases 2, 4, and 5 did well. 

Case 6 also fi nally did well, though it caused much 
trouble before it quieted down. 

If we take it that an eye was lost out of six, it gives 
the enormous percentage of 16-66, though the cases are 
far too few for this really to represent fairly the result. 
However, the operation is not one to be recommended iu 
preference to the more usual methods. 

Appended is a short abstract of the notes of these six 
cases. 

Lamellar Cataract Extraction. 

Case 1. — Girl, get. 12. Dense lamellar opacity. 

L. Extraction with Iridectomy. ISTo complication at opera- 
tion, except owing to sticky nature of lens. Subsequently 
inner angle of iris became drawn up to wound, and eye became 
considerably inflamed. Discharged from hospital 14 days after 
operation, but returned in another fortnight with severe iritis, 
for treatment of which patient was re-admitted to the hospital. 

Case 2.— Girl, art. 9. 

L. Extraction with Iridectomy. Uncomplicated ; lens very 
sticky, and some cortex left behind. Eye did not resent 
operation. 

2 I 2 



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482 OPERATIVE TREATMENT OF LAMELLAR CATARACT. 

Case 3. — Boy, ret. 9. Not very dense cataract. 

L. Extraction without Iridectomy. Vitreous presented almost 
immediately, and a small portion was lost ; lens nucleus alone 
appeared to come away. Subsequently the iris became prolapsed 
in scar, and severe irido-cyclitis with much keratitis punctata 
followed. Finally globe began to shrink, and eye was excised 
two months after operation. 

Case 4. — Girl, set.. 14. Very dense lamellar opacity. 
B. Extraction with Iridectomy. No complications. Eye did 
quite well, and Y. subsequently 6/12, and J. 1, with correction. 

Case 5. — Girl, set. 6. Lamellar cataract, with history of 
increase of the opacity during last two years. 

B. Extraction with Iridectomy. Peripheral section of capsule. 
Opacity at anterior pole did not come away with lens. Eye 
did quite well. 

Case 6. — Boy, set. 7. Dense lamellar cataract. 

B. Extraction without Iridectomy. Lens delivered through 
wide corneal incision. It was very sticky, and was removed in 
bits after much difficulty. Four days later eye became very irrit- 
able, due to some lens and capsule entangled in corneal wound. 
T. — . The wound was consequently re-opened and some cap- 
sule withdrawn • vitreous presented. A few days later a strand 
of capsule attached to corneal wound was divided. Eye subse- 
quently quieted down. 

This investigation being undertaken from a purely 
clinical standpoint, it would be out of place to speculate 
as to the cause of the suppuration and other complica- 
tions which unfortunately occur; suffice it to say, however, 
that in all cases the greatest care is taken to prevent in- 
fection by means of the instruments which are used : they 
are all boiled, soaked in 1—20 carbolic, and are taken, 
from a bath of 1 — 40 by the surgeon immediately before 
use. 

In summarising the results of this important class of 
case it is obvious that we cannot always be certain of 
getting a good result, the clanger of complications arising 



Hosted by GOOgle 



OPERATIVE TREATMENT OF LAMELLAR CATARACT. 483 

being considerably greater than in senile cataract. The 
best operation that we have at present is needling, fol- 
lowed, if necessary, by curette evacuation, which should 
always be done, if possible, before the onset- of acute 
symptoms. It appears probable that iritis following these 
operations is usually of a septic nature, though the mere 
mechanical irritation of swollen lens matter may be suffi- 
cient to determine it. 

It is far better to freely open the capsule than to stir 
up the lens matter through a small opening in it; in the 
former case should tension come on, the broken up 
material can be readily let out, but in the latter case the 
greatest difficulty may be experienced before this can be 
done. 

Suction is not an operation which appears to be often 
required. It is more dangerous than curette evacuation, 
and probably in nearly all, if not in all cases as much lens 
matter as it is possible to remove with safety can be got 
away without the aid of the syringe. t 

It is running an unnecessary risk to use a complicated 
syringe, the nozzle of which is difficult to get thoroughly 
clean, when a simple curette will do quite as well. Great 
harm may result by prolonged attempts at the removal of 
small pieces of lens matter which will themselves absorb 
without difficulty if left alone. 

Appended is a short resume of the results obtained in 
the iirst group of operations. 



No. of 

cases. 



1. Needling 

2. Needling and curette 

3. Needling and suction 



123 
113 



260 



No. of needlinsrs. 



1. 2. 3. 4. 5. M. 7. 




33. 53. IS. 10. 7. 1. 1. 


8 
1 




1 








10 



Suppura- 
tion. 



Exci- 
sion. 



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484 



AN HISTORICAL REVIEW AND CRITICISM OF THE BACTE- 
RIOLOGICAL HISTORY OF TRACHOMA, WITH PERSONAL 
OBSERVATIONS ON FIFTEEN CASES. 

By Arnold Lawson, F.RC.S. (Eng.). 

There is probably no disease which has given rise to so 
much discussion amongst those who are interested in the 
bacteriology of the eye as trachoma. The specific origin 
of this disease has been the subject of numerous papers 
from the pens of Continental and American observers, but 
English ophthalmologists have, up to the present time, 
contributed very little to the literature of this affection ; 
probably because the disease does not hold the same pro- 
minent position in this country as in many others. 

I have therefore thought that it might be of interest 
to give a short historical review of the published researches 
into the bacteriology of this disease before proceeding to 
any personal observations of my own upon the matter. 

The first published observations on the microbial 
origin of trachoma came from Iiirschberg and Krause 
(Centralblatt f. prakt. Augenheilk.) in the year 1881. 
These authors announced that they had discovered club- 
shaped micro-organisms, in the secretion obtained during 
the acute stages of trachoma, but had failed to find them 
in the chrome stages of the disease. During the same 
year Sattler read his first paper on the subject before the 
Congress at Heidelberg, when he stated that he had 
isolated a special micrococcus from the lids of patients, 
affected with trachoma. These micrococci were circular 
in shape and most usually united in series of threes or 
fours, but never appeared in chains as Streptococci, nor 
in large masses as Staphylococci. They were also motile. 
With inoculations of pure cultures of this micrococcus, 
Sattler claimed to have succeeded in producing trachoma 



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BACTERIOLOGICAL HISTORY OF TRACHOMA. 485 

in man, but had failed in all attempts to transmit the 
disease to animals. 

In 1882 Sattler read a second paper on the subject 
before the Ophthalmological Society of Heidelberg. He 
had made further extended researches, and described a 
case in which he said he had successfully produced 
trachoma by inoculating a culture of his micrococcus into 
the conjunctiva of a little girl. No histological examina- 
tion had, however, been made of the patient's conjunctiva, 
so that positive proof of his success was lacking. 

Two years later, 1884, found Koch in Egypt studying 
the origin of cholera, and whilst thus engaged he also 
undertook some researches into the origin of Egyptian 
ophthalmia. He found many varieties of micro-organisms, 
and isolated, amongst others, a bacillus analogous with 
that of mouse septicaemia. This bacillus is apparently 
identical with that described later by Kartulis and Weeks, 
and known now as the Koch-Weeks bacillus. This bacil- 
lus is now generally believed to be the specific organism 
in " pink eye," or acute catarrhal conjunctivitis. 

In 1885 Raehlmann, in a treatise on trachoma (Samml. 
Klinisch. Vort. herans v. Volk, Leipzig, 1885), announced 
that he had isolated small round micrococci, and Poncet 
(Gaz. desllop., 1886) in the following year also succeeded 
in isolating a definite micrococcus. 

During this year (1886) Michel published in the 
Archiv f. Augeiiheilkuncle the results of his extensive 
researches as to the specific origin of Egyptian ophthalmia. 
Michel's conclusions may be shortly summarised as fol- 
lows : — 

(1) The definite specific micro-organism of trachoma 
is a micrococcus which should be sought for in the 
trachoma follicles themselves, and not in the conjunctival 
secretions. 

(2) Morphologically this micrococcus, which he styles 
the trachoma coccus, is a diplo coccus, very small in size 
and biscuit-shaped. The dividing line is very narrow. 



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486 



HISTORICAL REVIEW AND CRITICISM OF TBS 



(3) Biologically it is non-motile, hut exhibits marked 
rotatory and oscillatory vibrations. It is strictly aerobic. 
It grows slowly and scantily on nutrient gelatin which is 

non-liquefied. On agar-agar and blood-serum at blood heat 
the growth is rapid and abundant, and spreads out like a 
white cloud. In consistence it is viscid, adhering to the 
platinum needle. On potato the growth is very scanty. 

(4) True trachoma is induced by the inoculation of 
pure cultures of this micro-organism into the human con- 
junctiva. 

Logetchnikow (Trav. de la Soc. Phys. Med. cle 
Moscou, 188G) has endeavoured to discredit these re- 
searches of Michel by stating that the latter mistook 
an epidemic of follicular conjunctivitis for true tra- 
choma. 

In 1887 Koucherski (Centr. f. prakt Augenli., 1887) 
published the result of his labours. He made separate 
examinations of the conjunctival discharge and of the 
trachomatous follicles. In the former he encountered 
varieties/ of micrococci and bacilli either associated 
together or as. pure growths. In the trachomatous 
follicles he discovered small diplococci, which he styled 
"trachoma cocci." These cocci liquefied gelatin, and 
microscopically resembled the gonococci of Neisser. The 
author inoculated various animals, rabbits, pigeons, dogs, 
cats, &c, with pure- cultures of the orgaiusm, but met 
with no success, and was equally unsuccessful in five 
cases where he endeavoured to induce trachoma in man. 

The next article on the subject was a thesis written 
by Schmidt for his degree of Doctor of Medicine. Th 
writer drew distinction between the coccus described by 
Sattler and that described by Michel, giving it as his 
opinion that Michel's coccus was the microbe of acute 
blenorrhcea, or of trachoma complicated by acute blenor- 
rhoea. He himself had isolated a micrococcus much resem- 
bling the Staphylococcus pyogenes, but larger, less motile, and 
liquefying gelatin less quickly. This coccus appeared to 



e 



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•BACTERIOLOGICAL HISTORY OF TRACHOMA. 487 

be identical with that described by Sattler. He further 
claimed to have succeeded in inducing trachoma in birds 
and animals, although repeated inoculations were required 
in the case of mammals before he met with success. 

In 1888 Staderini (Ann. d'Ocul., xcix) succeeded in 
isolating a diplococcus resembling the gonococcus, but 
smaller. He inoculated the micro-organism into animals 
which were kept in unsuitable and unhealthy surround- 
ings, with a view to form a predisposition to disease. He 
came to the following conclusions: — Inoculations of the 
diplococcus into the conjunctival sacs of rabbits gave rise 
to a trachomatous conjunctivitis in those animals which 
were badly nourished and crowded together, whilst the 
result was negative in those rabbits that were well fed 
and had plenty of air space. The author went on to say 
that the follicles of trachoma were due to the irritation set 
up by micro-organisms, the process being accompanied by 
an exudation of leucocytes. 

The above paper was followed shortly afterwards by 
an article by Petresco, of Bucharest (Ann. d'Ocul., xcix), 
in which the author stated that besides many varieties of 
cocci and bacilli, he had isolated a special micrococcus, to 
the presence of which he attached considerable import- 
ance, This micrococcus differed from Michel's coccus in 
the fact that it liquefied gelatin. It could be distinguished 
from the gonococcus of Neisser by staining well by 
Gram's method, and from the coccus described by Poncet 
in 1886 in being found in the trachomatous follicles and 
not only in the conjunctival discharge. All the author's 
efforts, however, to induce trachoma in animals were 
unsuccessful. 

During the next year (1889) Reid, in a paper read 
before the Ophthalmological Society of the United King- 
dom, declared his inability to find any special micro- 
organisms whatever in trachoma. 

In 1890 the question of the origin of trachoma was 
discussed at the Ophthalmological Section of the Interna-. 



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488 HISTORICAL REVIEW AND CRITICISM OP THE 

tional Medical Congress held at Berlin. MM. Raehlmann, 
Schmidt-Rempler, Swaen-Burdet, Sattler, and Chibret 
took part in the discussion, and whilst all these authorities 
were unanimous in recognising an undoubted infective 
process in trachoma, not one investigator could secure 
universal approval for the specific nature of any one par- 
ticular microbe. During this same year Shongolowitch 
wrote a thesis on the subject for his degree of Doctor of 
Medicine. He stated that he had succeeded in inducing a 
granular conjunctivitis in rabbits and cats by inoculations 
of pure cultures of a particular bacillus which he had suc- 
ceeded in isolating from the contents of trachomatous 
follicles. The bacillus was characterised by its small 
size, its slenderness, and by its imperviousness to ordinary 
stains. 

A fresh impetus to the question was given next year, 
1891, by an article by Noisewski (Archiv f. Augenh., 
1891), who brought forward an entirely new specific 
agent for trachoma in the shape of a bacterium closely 
allied t.6 the " microsporon furfur of Kaposi." To this 
he gave the name of the " microsporon trachoinatosam." 

Noisewski absolutely denied the specific nature of any 
of the, micro-organisms described by other writers, and 
declared that true trachoma had resulted in four or five 
weeks after inoculation of his " microsporon trachoinato- 
sam " into the conjunctival sacs of rabbits. 

In the latter half of the same year a paper appeared 
in the Ophthalmic Record in which the author, Fulton, 
expresses his belief in the specific nature of Michel's 
micrococcus. 

The advancement of all these varied organisms, to each 
of which a specific nature had been so readily ascribed by 
its enthusiastic discoverer, naturally enough led to a 
reaction in thought, and Mutermilch, in 1893 (Ann. 
d'Ocul, cix), wrote a paper on " The Nature of Tra- 
choma," the sum of which amounted to a total denial of 
the contagious character of acute trachoma. 



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BACTERIOLOGICAL HISTORY OF TRACHOMA. 489 

He was followed by Guenocl (Gaz. des Hopitaux, 1894), 
who expressed great doubt as to the existence of a special 
micro-organism in trachoma. " Although," he says, " the 
contagious character of the granulations is supported by 
weighty arguments, one cannot help thinking that tra- 
choma, having regard to the strict localisation of the 
disease in lymphoid tissue, has an endogenous origin/'* 

Fuchs now enters into the controversy, and during this 
same year (1894) he published his opinion on the subject 
in his Text-book on Ophthalmology. It may be sum- 
marised as follows : — The ultimate origin of the disease 
is probably the gonococcus. The gonococcus transferred 
to the conjunctiva causes an acute gonorrhoea! ophthalmia, 
and when this becomes chronic a similar transference of 
the infective material gives rise to trachoma. 

This opinion of the gonorrhoeal origin of trachoma is 
shared by Hoor, who wrote a paper to this effect during 
the following year (1895). 

A strong supporter of Mutermilch's views pame for- 
ward this year (1895) in the person of Gunning (Gennesk 
Tydssler, 1895). This author expresses his disbelief in 
the contagiousness of trachoma. Pie says that there is 
no mucous or purulent secretion peculiar to trachoma ; 
the presence of such secretion indicating the presence of 
complications either of acute catarrhal or of purulent con- 
junctivitis. The proofs of the non-contagiousness of tra- 
choma lie (1) in the fact that it is frequently confined to 
one eye, and (2) that the inoculation of the discharge 
from trachomatous eyes produces only a catarrhal inflam- 
mation, and not trachoma. 

On the other hand, Van Millingen (Ann. d'Ocul., cxiv, 
1895) published about the same time the results of exclu- 
sive researches that he has made on the subject, and he is 
strongly of opinion that trachoma is both infectious and 



contagious. 



Lastly, in the following year (1896) an admirable 
thesis, written by Oazalis for his " Doctorat " at the Uni- 



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490 HISTORICAL REVIEW AND CRITICISM OF THE 

versity of Montpellier, brings us to the most recent ex- 
tended investigations on the subject. To this thesis— 
which is not in general circulation, and so not easily ob- 
tainable — I am indebted for much valuable information in 
compiling this short historical review. It will be interest- 
ing to give a few notes on the results of Cazalis' work. 

Cazalis isolated from cases of trachoma three varieties 
of bacilli : — 

(1) Koch-Weeks' bacillus. 

(2) Club-shaped bacillus, frequently found associated 

with the Koch-AVeeks' bacillus, and probably 
identical with the pseudo-diphtheritic bacillus. 

(3) A bacillus characterised by bi -polar staining and 

by being decolorised by Gram's method. 

Inoculations of pure cultures of bacilli (Nos. 2 and 3) 
into the -conjunctival sacs of animals set up a muco-puru- 
lent conjunctivitis with severe reaction and accompanied 
by temporary enlargement of the conjunctival follicles. 

Cazalis further isolated and experimented with a 
sireptothrix (Strep to thrix Fce-rsLerii) which he encountered 
associated with a micrococcus, but he met with no positive 
results. 

As regards micrococci, Cazalis isolated the gonococcus 
in one case, and frequently found staphylococci and 
streptococci. He also succeeded in obtaining pure cul- 
tures of the Sattler-rMichel micrococcus in two cases. This 
latter micrococcus he found in the conjunctival secretions, 
on the surface of the conjunctiva, and in the substance of 
the trachomatous follicles. He experimented with this 
micro-organism on animals, but in all cases his results 
were negative. 

Cazalis concludes his personal observations by confes- 
sing his inability to assign a specific nature to any particu- 
lar micro-organism. 

Since Cazalis' paper, UhthofT has published, during the 
last months of 1897, a monograph upon the bacteriology 



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BACTERIOLOGICAL HISTORY OF TRACHOMA. 491 

of conjunctivitis, and in speaking of trachoma, lie ex- 
presses his firm belief in the existence of some special 
specific organism which at present is unknown. 

Observations on Personal Researches. 

The subjoined notes relate the results of the bacterio- 
logical examination of 15 cases of acute trachoma. They 
are simply intended as a preliminary record of an investi- 
gation into the subject upon which I have been engaged 
for some time past at the British Institute of Preventive 
Medicine, and do not pretend to any authoritative or dog- 
matic statements. I venture to relate them as a personal 
addition to this short paper. I take this opportunity to 
tender my best thanks to the Institution of Preventive 
Medicine for the great facilities offered me, and to Dr. 
Allan Macfadyen and Dr. W. Hewlett, the director and 
assistant bacteriologist, for their most kind and able 
assistance. 1 

I primarily undertook this investigation to endeavour 
to find out in what percentage of cases of acute trachoma 
the Sattler- Michel micrococcus would be found ; and for 
this purpose I determined to compare cases of Egyptian 
trachoma with cases met with in this country. Whilst 
engaged on this I also paid attention to any other organ- 
isms encountered. 

Mr. Kenneth Scott, of Cairo, most kindly sent me over 
from Egypt 12 agar-agar tubes, inoculated with the fol- 
licles of 12 cases of Egyptian trachoma, upon which he 
had operated by expression of the follicles.. The tracho- 
matous follicles were rubbed on to agar-agar tubes, and' 
then immediately despatched to England, where they 
arrived about a week later. A series of agar-agar plates 
was made from the tube on arrival, and the various colo- 
nies examined and transferred on to other media. Three 
of the tubes were spoilt on transmission, so that I have 
only records of nine out of the 12 cases. 



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492 HISTORICAL REVIEW AND CRITICISM OF THE 

The remaining six cases were obtained from the 
ordinary practice at Moorfields, by the kindness of some 
of the staff. Much the same methods were employed as 
in the Egyptian cases, viz., the follicles were expressed, 
and then agar-plates and peptone-broth inoculations were 
made. From these, again, fresh inoculations were made 
on to other media. All the 15 cases suffered from what 
is generally known as acute trachoma, that is to say, the 
disease was recent, the lids covered by abundant red 
fleshy granulations; there was an accompanying muco- 
purulent discharge, and the subjective symptoms were 
well pronounced. 

As regards the Sattler- Michel micrococcus I have only 
been successful hi isolating it definitely in two cases, both 
of which occurred at Moorfields. In one of the Egyptian 
cases it was apparently found, but in spite of every care an 
absolutely pure culture could not be obtained. In both of 
the English cases also, in which it was isolated in pure 
culture, much difficulty was experienced. I should like at 
this point, to enter a protest against this micro-organism 
being termed a diplococcus. It was puzzling to find that 
a micrococcus, which in its biological characters bore out 
everything that was described as peculiar to the Sat tier- 
Michel coccus, to have, when grown on agar-agar or on 
blood serum, very definite grouping like a staphylococcus, 
from which it could not be discriminated. Cultures in 
peptone-broth or on gelatin did, however, show distinct 
grouping of the coccus in twos and fours. To clear the 
point up, Dr. Macfadyen most kindly obtained a pure cul- 
ture of the coccus from Professor Sattler's laboratory, and, 
on comparing growths from this tube with my own, I 
found the same feature present, that is to say, that upon 
agar-agar and blood serum the coccus was arranged in 
masses like any staphylococcus, there being only occasional 
diplococci to be seen, as always occurs in detached frag- 
ments of a mass of staphylococci. 

Varieties of staphylococci were found in every case, 



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BACTERIOLOGICAL HISTORY OF TRACHOMA. 498 

either the Staphylococcus pyogenes aureus, which was 
present in two cases, or the Staphylococcus pyogenes albus. 
In one or two cases the Staphylococcus epidermidis albus 
was thought to be found. This micro-organism only 
differs from the Staphylococcus pyogenes albus in liquefying 
gelatin rather less speedily. 

Sarcinae were found in two cases. 

Bacilli were found in five cases. 

One variety of bacillus encountered was a non-motile 
bacillus, decolorised by Gram's method of staining. Nu- 
trient gelatin was not liquefied, and gave a plentiful white 
semilucent growth. On agar-agar there was produced an 
uniform dull white cloud-like film, and a very similar 
growth was obtained on serum. On potato a thick white 
creamy, though not very abundant growth resulted, and 
inoculation of milk did not cause coagulation. Inoculation 
of a pure culture of this bacillus into the conjunctival 
sac of a rabbit produced a severe reaction, arid a fairly 
profuse muco-purulent discharge ; whilst the conjunctival 
surface became speedily covered by red velvety granu- 
lations. The whole process had subsided in about a 
fortnight, at the end of which period the conjunctiva had 
regained its normal appearance, and all discharge had 
ceased. 

The Bacillus ones enter icus vulgatus was isolated from 
another case ; but, of course, this bacillus has no patho- 
logical significance. The other varieties of bacilli were 
not unfortunately followed up to a precise identification. 
One was a chromogenic bacillus which yields an* abundant 
smooth yellow growth on agar-agar and serum, whilst 
nutrient gelatin was not liquefied, and only showed a very 
feeble growth. Each of these varieties of bacilli only 
occurred in one case, and in putting the cultures aside to 
be able to recognise any second appearance of the same 
bacillus in another case, the growth was allowed to die 
out. 

Thus so far, no variety of micro-organism, with the 



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494 HISTORICAL REVIEW AND CRITICISM OF THE 

exception of staphylococci, lias been found present in m6re- 
tlian two out of the- 15 cases. Varieties of staphylococci 
were found in all cases. It is one of the essential character- 
istics of any micro-organism for which a definite specific 
nature is claimed, that it should be found in all well-marked 
and acute cases of the disease in question, and, as far as my 
experience goes, the Sattler-Michel coccus is very far from 
fulfilling this condition. 

In short, I have been unable to discover any micro- 
organism, without reference to any pathogenic properties 
it may possess, the mere presence of which may be re- 
garded as a chara cteristic microscopical feature of trachoma. 
As I have, however, already pointed out, my investigations 
into this subject are at present incomplete. 

- General Conclusions. 

Three questions naturally suggest themselves on study- 
ing the combined results of the numerous writers on the 
bacteriology of trachoma. 

1. Has trachoma a bacterial origin or not ? 

2. Has any micro-organism been isolated which may 

claim to be the etiological factor of ihe disease ? 

3. Is it possible that trachoma is induced by a variety 

of micro-organisms rather than by one definite 
microbe ? 

L Has trachoma a bacterial origin or not? 

On this point the mass of evidence is largely in favour 
of a bacterial origin for trachoma, and despite the argu- 
ments evinced by Miittermilch and Gunning to the con- 
trary, such an opinion seems almost conclusively proved. 
The question chiefly turns on the contagiousness or 
otherwise of the disease. I say chiefly, because we have 
still to contend with the possible advent of a specific pro- 
tozoon, though up to the present time all attempts to prove 
the existence of such a parasite have failed. The evidence 



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BACTERIOLOGICAL HISTORY OF TRACHOMA 495 

of repeated epidemics of trachoma, and of cases where the 
disease has spread directly from one person to another 
of a co mm unity are too numerous and well assured to 
admit of doubt. In all probability the contagiousness of 
the disease is very variable, being, under certain conditions 
much greater at one time than another. Thus the disease 
may assume an acute epidemic form when it appears to be 
highly contagious, whilst at other times it makes its 
appearance in isolated chronic cases, lacking the acute 
symptoms of the epidemic form. In this latter manifesta- 
tion the conditions favourable for the spread of the disease 
do not seem to exist, and the power of transmission is 
much lessened. In such cases only one eye may be 
affected, though this is rare, and the second eye usually 
becomes implicated at some later period. The conditions 
which chiefly influence the contagious character of the 
disease have been shown to exist in bad hygienic sur- 
roundings ; and in this respect trachoma does not differ 
from many well known and undisputedly contagious dis- 
eases such as diphtheria and typhoid, plague, and cholera. 

Mr. Ridley, in an interesting paper on the histology of 
trachoma (Trans. Ophth. Soc. U. K., 1894), gives four 
arguments against the bacterial origin of trachoma. As 
in these four arguments Mr. Ridley sums up the points that 
have been most generally adduced against the bacterial 
theory, I venture to offer a few words of criticism in reply. 

He quotes, firstly, the great diversity of opinion as to 
the etiology of the disease, " that many micro-organisms 
have been found, that to many a specific nature has been 
assigned ; but in all cases conclusive proofs have been 
wanting. On the other hand, equally competent observers 
have found no special micro-organisms." 

As regards this point, it must be remembered that one 
great difficulty in discovering a specific microbe, lies in 
the resistance offered by animals to the disease. Trachoma, 
as far as one can judge, is a disease peculiar to man ; 
moreover, the presence of a multiplicity of bacteria is by 
VOL. xiv. 2 K 



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496 HISTORICAL REVIEW AND CRITICISM OF THE 

no means a conclusive proof of the absence of a specific 
bacterial process, a point to which I shall refer later. 

Secondly, Mr. Eidley suggests that a parasitic Proto- 
zoon may be the etiological factor.. 

The importance of parasitic Protozoa in the causation 
of disease is now becoming widely recognised, and a 
parasite has been definitely proved to be the specific 
cause of malaria ; but the presence of a Protozoon of this 
description in trachoma is, after all, only hypothetical, 
and the mere possibility of its presence can hardly be 
used as an" argument against the bacterial theory in a 
disease where bacteria actually abound. 

With reference to the possibility of a parasitic origin 
in trachoma, Mr. Ridley states that " bacterial diseases are 
usually more easily communicable, whilst those due to 
Protozoa vary in the extreme." This is a loose statement. 
Leprosy and tubercle are both bacillary diseases, and 
both are contagious, though not markedly so ; and a man 
may live for years in close communication with patients 
suffering from one of these diseases and yet escape con- 
tagion. As has already been pointed out, the contagious- 
ness of trachoma is probably very variable, and when one 
takes into consideration the normal inhibitive power of 
healthy tissue, one can, at any rate, hardly expect the 
attenuated virus of chronic and isolated cases to induce 
trachoma in a healthy conjunctival sac. The only true 
test of the contagiousness of trachoma lies in the question 
of its transmissibility in its acute epidemic form ; when 
there can be no reasonable doubt that active agents such 
as flies, or passive agents such as sponges, towels, &c, do 
directly carry and spread the disease throughout a district 
or community. 

As a third argument, Mr. Ridley cites the great power 
of trachoma in resisting ordinary bacteria-destroying 
agents. Here we are confronted by the question as to 
whether these bacteria-destroying agents do, in a large 
number of cases, ever reach the true source of disease, 



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BACTERIOLOGICAL HISTORY OF TRACHOMA, 4^7 

which probably lies in the sub-epithelial layers. If these 
layers are exposed with a strong solution of corrosive 
sublimate, then Mr. Kenneth Scott has shown that the 
disease can be cured by this powerful germicidal agent in 
a few weeks. 

Lastly, the absence of giant cells in trachoma presents 
a difficulty to Mr. Ridley. He says that " these giant 
cells seem to him to be the tissue's special means of attack- 
ing slowly growing organisms, such as tubercle, while the 
leucocytes and epithelioid cells suffice for their chemical 
products only." 

Surely this is rather a startling assumption to use as 
an argument against the bacterial origin of trachoma. 
There are, no doubt, writers who support Mr. Ridley in 
his views as to the uses of the giant cells in tubercle ; but 
as regards the object of the leucocytes, a very large and 
influential school, headed by MetschnikofF and others, 
believe that the leucocytes are themselves the main 
agents in attacking and consuming hostile micro-organ- 
isms. So that with equal authority one might quote the 
exudation of leucocytes in trachoma as a proof of the 
bacterial origin of the disease. However, it would appear 
that neither the absence of giant cells nor the presence of 
leucocytes, the exact uses of which are, after all, some- 
what hypothetical, can have much weight in the question 
of a bacteria] or non-bacterial origin for this disease. 

2. Has any Micro-organism been isolated which can claim to 
be the Etiological Factor of the Disease ? 

Unquestionably no organism has been isolated which 
fulfils the necessary conditions appertaining to a specific 
organism. The bacterium most favoured by the majority 
of writers is that advanced by Sat tier and Michel; whilst 
many others, including Fuchs, believe the virus to be an 
attenuated form of the gonococcus. Some writers in 
relating positive results in their experimental inocula- 

'2 K 2 



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498 HISTORICAL REVIEW AND CRITICISM OF THE 

tions of animals may have mistaken a severe follicular 
conjunctivitis with mu co-purulent discharge for true 
trachoma. This variety of conjunctivitis may be induced 
by many micro-organisms, and I have myself succeeded 
in doing so with a certain bacillus discovered in one case. 
Before any micro-organism can have any special claim to 
be regarded as specific, an histological examination must 
be made of the follicles, the formation of genuine granu- 
lation tissue established, and the organism found repro- 
duced. These conditions have not yet been fulfilled by 
any investigator. 

3. Is it possible that Trachoma is induced by a variety of 
Micro-organisms rather than by one Special Microbe ? 

The possibility of such a solution of the question is the 
natural, thought that follows a review of the bacterio- 
logical history of trachoma. Such a theory implies an 
origin liy mired infection, a condition of which there are 
some well-known instances scattered through the science 
of bacteriology. For example, the alliance of a strepto- 
coccus with the Klebs-Loeffler bacillus is responsible for 
certain special clinical symptoms that may complicate 
diphtheria ; and we further believe that the union of a 
streptococcus with the unknown specific organism of 
scarlatina is the specific cause of scarlatinal nephritis. 
The clinical symptoms of pure streptococcic icfection are 
either those of a general acute septicemia or of a local 
erysipelas; but when the organism becomes associated 
with the Klebs-Loeffler bacillus or the supposititious 
scarlatinal organism, the result is not an acute septicemia 
or a local erysipelas added on to the ordinary clinical 
manifestations of diphtheria or scarlatina, but the produc- 
tion of new and special symptoms due to the alliance ot 
two distinct pathogenic organisms. 

If we apply this theory to trachoma, we note two 
main clinical features of the disease. Firstly, we have a 



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BACTERIOLOGICAL HISTORY OF TRACHOMA. 499 

muco-purulent discharge and a coincide!) f inflammation of 
the conjunctiva ; and, secondly, we see the special mani- 
festation of trachoma in the presence of bunches of granu- 
lation tissue which are known as the trachoma follicles. * 

Now, all the known specific agents of a muco-purnlent 
conjunctivitis have been found and isolated in trachoma, 
staphylococci and streptococci in several varieties, Weeks' 
bacillus, and other varieties of bacilli which are known 
to produce a muco-purulent conjunctivitis, but which 
have not been identified with any special form of inflam- 
mation. Any of these organisms, then, may produce a 
muco-purulent conjunctivitis, but not any single one, 
apparently, may produce trachoma. It is possible, per- 
haps even probable, that the accidental union in the con- 
junctival sac of two or more of these pathogenic organ- 
isms may be the specific cause of the special features of 
trachoma. 

This theory of the mixed infection of trachoma must 
rest for the present on an hypothetical basis ; ', but, at 
least, it opens up a fresh field for investigating the origin 
of the disease, a field which, I venture to believe, will not 
be unproductive in its results. 

It is worthy of note that during the last few weeks, 
L, Muller. of Vienna, has published a paper alleging his 
discovery of a specific bacillus in trachoma (Wiener 
klinische Wochenschrift, 1897). Unfortunately the publi- 
cation is too recent for me to be able to obtain it in time 
for this paper. 



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500 



DESCRIPTIVE CATALOGUE OF SPECIMENS IN THE 
HOSPITAL MUSEUM (continued). 

By C. Devereux Marshall, Curator. 

Series I. 
Sub series (A) — continued. 
No. 32 (4542).— The lateral half of the right eye of 



a 



woman, aged 66, who was struck with a piece of wood she 
was chopping. The eye was extremely painful, and the sight 
was lost a week after the accident. Excision was performed 
two weeks later. Tension -f2. The cornea is very steamy, 
and the lens is lying in the anterior chamber and completely 
filling it. The iris is tightly stretched behind it, but at the 
periphery it is lying against, and adherent to, the cornea, thus 
closing the angle of the anterior chamber. The ciliary body 
is stretched and thin, and microscopically it is seen to be much 
inflamed. ^ 

No. 33 (4413).— Lateral half of the left eye of a man which 
was injured nine years ago by a piece of wood that he was 
chopping flying up and striking it. The sight gradually failed 
after this. It has lately given rise to much pain. The globe 
is somewhat enlarged, the sclera is bulged in places, and the 
anterior chamber is rather deep. The lens is displaced, cal- 
careous, and very hard. The vitreous is detached and shrunken, 
but it is adherent to the disc and a portion of the retina near 
this. The retina is in situ. 

No. 34 (4300).— The lateral half of the left eye of a youth, 
acred 17. It was struck with a stone thrown from a catapult 
seven years previously ; the sight failed about two years later. 
The cornea is clear, and the anterior chamber is of irregular 
depths; iris bombe. The angle on both sides is closed by 
adhesion of the root of the iris to the cornea. The lens is 
opaque and calcareous at its periphery. The retina is detached 



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SPECIMENS IN THE HOSPITAL MUSEUM. 501 

from the optic disc to the ora serrata. The cell elements appear 
microscopically to be diminished, but the interstitial tissue is 
increased. 

No. 35 (4505).— Section of the left eye of a man, aged 24, 
which was injured 10 years before excision with a squib. 
For two years it has been quite blind. The eye was very 
painful and inflamed when removed. The angle of the anterior 
chamber is entirely closed by adhesion of the root of the iris to 
the cornea. The iris is bombe, and the pupil is entirely bound 
down to the lens capsule. The lens was lying in the cavity 
seen, but it was calcareous, and has since become displaced. 
The retina is detached from the optic disc to the ora serrata, 
and on one side there is a large cyst in it. The subretinal 
space was filled with a mass of coagulated albuminous material. 
Microscopically it is seen that the iris is atrophied, the ciliary 
body, choroid, and retina are all thickened and infiltrated, but 
there are no small retinal cysts as is usually the case. 

No. 36 (5044). — The right eye of a man, which had been 
blind for 20 years after having received several blows upon it. 
The anterior chamber is shallow. The lens is calcareous. The 
choroid is detached, and beneath it is a mass of blood clot 
behind and jelly-like material at the sides ; in the choroid itself 
is a large mass of bone forming a cup, and in the middle of 
this there is a large quantity of cholesterine which has an 
opalescent appearance. 

No. 37 (4825). — Section of the eye of a man, which was 
struck with a piece of wood seven years ago. The anterior 
chamber is very deep. The iris is much atrophied. The lens 
is absent. On careful inspection the vitreous is seen to form 
an umbrella-shaped detachment with its apex at the disc. 
There are some small patches of choroiditis. 

No. 38 (5103). — Section of an eye of a man, aged 78, who 
suffered from a traumatic ulcer of the cornea. The cornea is 
destroyed, and the retina and choroid are detached. The 
ciliary nerves can be seen stretching across the subchoroidal 
space. 



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5G2 DESCRIPTIVE CATALOGUE OF SPECIMENS 

No. 39 (172 O.P.). — The eye of a gentleman, who became 
suddenly blind in this eye when diving, 30 years before 
removal. At that time a large haemorrhage had taken place 
into the vitreous. The anterior chamber is of moderate depth, 
but the angle is somewhat narrowed. The lens was calcareous, 
but the capsule now only remains, the lens matter itself having 
come away in fragments. The vitreous, which has now been 
removed, was opaque and rather dense. In the choroid is a 
large bony plaque. There is extensive retino-choroiditis, and 
the retina is so altered and adherent to the choroid as to be 
hardly recognisable. 

No. 40 (5268). — Right eye of a man, aged 54, which was 
struck with a flat piece of wood four years ago — it was quite 
healthy until that time. The left e}^e is myopic to the extent 
of about —3 D. The eye is soft; tension —3. The cornea is 
hazy, and the anterior chamber is very shallow. Total 
posterior synechias. The lens, which is now displaced with its 
anterior surface visible, is in a large space bounded in front by 
the iris awcl ciliary body, and behind by a dense cyclitic mem- 
brane. There is an anterior polar opacity also present. The 
cyclitic membrane has undergone some contraction, and this 
has led to the detachment of the adjacent choroid. It forms 
the anterior boundary of a rather larger cavity, which is full of 
cholesterine. The retina is indistinguishable even micro- 
scopically. 



SERIES I. — Subseries (G) — continued — Eyes not containing 
Foreign Bodies. 

No. 45 (4834). — Section of the eye of a boy, aged 14, which 
was wounded with a stone 11 years before removal. Ifc was 
increasing in size and also becoming painful. The eye is much 
enlarged in all directions. The cornea is thin, and with the 
much thinned ciliary region forms a large anterior staphyloma. 
The iris is very atrophied, and is adherent to the cornea. The 
lens is opaque and shrivelled, and is displaced somewhat to one 
side and held there by the suspensory ligament. The vitreous 



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IN THE HOSPITAL MUSEUM. 



503 



is fluid and degenerated. The retina and choroid are intact, 
but both much atrophied. The optic disc is deeply cupped. 

No. 40 (66 O.P.) — The eye of a boy, aged 17, which was 
injured four years ago by a pen which penetrated close to the 
corneoscleral margin. It hardly touched the lens, but caused 
a small and localised opacity at the spot. The eye remained 
quiet until it was struck about two weeks before excision ; it 
then became inflamed, and was excised. The track of the 
pen through the periphery of the lens back into the posterior 
part of the ciliary region is well seen. 

No. 47 (4952). — Section of the eye of a man, aged 21, 
whose eye was injured 14 years previously with a fork. The 
lens became dislocated into the anterior chamber, and the eje 
then became painf ul. The anterior chamber is very deep, but the 
lens which was in it has fallen out; it was hard and calcareous. 
The retina is entirely detached, and the vitreous chamber is 
much contracted. In the choroid a large plate of bone is 
developed. 

No. 48 (4807). — The eye of a man, aged 24, which was 
injured 16 years before excision. It remained quite quiet until 
seven days ago. A large mass of cholesterine then appeared 
in the anterior chamber, and the eye became inflamed. There 
is a wound of the cornea with an anterior synechia attached to 
it. A large quantity of cholesterine was in the anterior 
chamber, and the subretinal space was nearly full of it, but 
has all got washed away except a small quantity in the anterior 
chamber. The lens is much degenerated, and the retina is 
detached from the optic disc to the ora serrata. 

(Reported in Ophth. Soc. Transactions, vol. xvi, p. 362.) 

No. 49 (5056). — The left eye was cut with a piece of copper 
five days before excision. An iridectomy for the prolapse was 
done. The wound is seen to extend through the cornea, iris, 
and lens, the latter being divided into two unequal halves. 
The vitreous is healthy, and the retina and choroid are in situ. 

No. 50 (4884). — Section of the eye of a man which was 



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504 DESCRIPTIVE CATALOGUE OF SPECIMENS 

injured nine years ago with a stone, since which time it has 
been shrinking. The cornea is flat, and the iris is adherent to 
it. The lens is absent, and the retina forms a solid mass which 
is detached except at the disc and at the anterior part. The 
choroid contains a thin plate of bone which has fallen forwards 
against the glass. 

No. 51 (5071). — Section of an -eye which was injured five 
years ago. There was no P.L., and T. was —3. There is an 
extensive wound reaching across the cornea, the scar of which 
is seen in the section; the iris is adherent to the back of the 
cornea. The lens is almost entirely absorbed, and what remains 
is quite opaque. The retina is entirely detached from the optic 
disc to the ora serrata, and the subretinal space is filled with 
coagulated albuminous material in which orystals of cholesterine 
are visible. 

No. 52 (5081). — Eye wounded three months before exci- 
sion; it is somewhat shrunken. The lens is dislocated. The 
vitreous is absent. The retina and choroid are detached. 



No. 53 >(4980). — Section of an eye injured by being struck 
with a brick. The eye has two lateral staphylomatous bulgings. 
The iris is greatly atrophied. The lens is dislocated into the 
subretinal space. The retina is completely detached between 
the optic disc and the ora serrata. 

No. 54 (4908). — The eye was injured three weeks before 
excision by a piece of steel. An ulcer with hypopyon followed, 
and this destroyed the cornea. There is much lymph about the 
wound, and the lens is lying between its lips where it is caught 
and moulded. The retina is slightly puckered. 

No. 55 (5011). — The eye of a child, aged 18 months. Six 
months previously it was injured with a pair of scissors. The 
cornea is wounded, and to this the iris and some capsule is 
adherent. The lens is absent. An extensive scar is seen 
runnino- from the wound across the retina and choroid to 
rather beyond the equator. The vitreous is degenerated. 

No. 56 (4429). — Eye of a young man which was wounded 



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IN THE HOSPITAL MUSEUM. 505 

by a piece of a rivefc; a small piece of metal was removed with, 
the magnet. The eye did not recover, and was removed. The 
lens is absent, and there is much inflammatory exudation 
around the ciliary body. Stretching between the O.D. and the 
remains of the lens is the coiled up and detached hyaloid 
membrane. 

No. 57 (4834).— The eye of a boy, aged 14, which was 
injured with a stone when he was three years of age. The eye 
is greatly enlarged in all directions ; the cornea is thin and 
bulged, and to this the iris is adherent, the thinning affects 
the ciliary region, and thus forms a large anterior and ciliary 
staphyloma. The remains of the lens, which is much broken 
up, can be seen at the lower part of the preparation. The 
vitreous is greatly degenerated. The retina and choroid are in 
situ, and the optic disc is deeply cupped. 

No. 59. — Section of an eye which was wounded through 
the cornea and pupil. The lens is opaque, and is breaking 
down at the posterior part, and here commencing to suppurate. 
There is an anterior capsular synechia adherent to th£ wounded 
cornea. 

No. 60 (5288). — Eye of a boy, which has a large wound of 
the cornea. An iridectomy was done, but the iris is not free. 
The lens is wounded, and two fine capsular synechias reach 
forwards, and are adherent to the corneal wound. 

No. 61 (5330). — Eye of a woman, aged 21, which was 
injured 16 years ago with a shrimp's head, and has been blind 
ever since. The cornea and iris are adherent, and the lens has 
nearly disappeared. The vitreous has degenerated, and the 
hyaloid membrane is detached and runs forwards like a cord for 
some distance, and then expands into a conical form (this can 
only be seen on close inspection). There is much inflammatory 
exudation covering the ciliary body. 

SERIES I. — Subseries (D) — continued — Eyes containing 
Foreign Bodies, 

No. 23 (4633). — The lateral half of the left eye of a man, 



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506 DESCRIPTIVE CATALOGUE OF SPECIMENS 

aged 49, which was struck with a piece of steel 16 days before 
excision. It caused a wound of the sclerotic f inch to the 
inner margin of the cornea. Lying at the lower part of the 
ciliary body is a piece of steel, 13 mm. long and 3| mm. wide. 
There is some hasinorrhage into it. The lens has escaped 
injury. 

No. 24 (4608).— The lateral half of the left eye of a man, 
which was injured with a piece of steel six years ago. The 
anterior chamber is of irregular depth, and the iris is bulged, 
the angle is closed on both sides, and the pupil is completely 
blocked and bound down to the anterior capsule of the lens. 
Lying embedded in the sclerotic and projecting into the 
vitreous is a splinter of metal, but it does not project on the 
outer side at all. The vitreous was rather fluid and the O.D. 
deeply cupped. 

No, 25 (4607). — A month before excision patient was 
struck in the right eye with a piece of metal. The cornea, 
iris, and lens were wounded. Lying at the lower part of the 
vitreous chamber, and in contact with the ciliary body, is a 
piece -of /iron surrounded by lymph. The vitreous is degene- 
rated, arid the retina is somewhat detached. 

ISTo. 26 (4925). — Three weeks before excision the left eye 
was struck with a piece of tin. There is a punctured wound of 
the cornea with a prolapsed iris. The lens is wounded opposite 
this, and the opacity is seen extending from it. A fragment of 
metal is lying in the ciliary body opposite the point of entry. 

'No. 27 (5037). — Four weeks before excision a piece of metal 
flew off a lath and struck the left eye. Situated by the ciliary 
body, and just behind the lens, is a small fragment of iron. 
The vitreous is shrunken and detached. The retina is in situ, 
and the choroid is slightly detached from the sclera in front. 

rJo. 28 (3871).— Section of the eye of a man who was fired 
at in the face by a poacher standing 3 yards away with a 
blank charge. The cornea, iris, and lens are wounded, and 
several grains of gunpowder are in (he vitreous. This is much 



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IN THE HOSPITAL MCJSEUM. 507 

infiltrated with inflammatory material. The retina and choroid 
are in situ. 

No. 29 (5063). — Section of the eye of a man which was 
wounded with a piece of steel. The corneal wound is seen, 
and, spreading backwards from it, is pus and inflammatory 
exudation. The retina at the posterior part is greatly thickened. 
The foreign body is covered with lymph, and is not seen. 

No. 30 (4925). — The eye of a woman, aged 23, which was 
wounded with a piece of tin, which penetrated. There is a 
punctured wound at the upper and inner corneo-scleral junction 
(seen on one side of the specimen), and in this the iris is pro- 
lapsed. The lens is wounded, and is becoming opaque. Sus- 
pended in the vitreous was an irregular-shaped piece of metal 
which is not now present. The retina' is somewhat detached. 

No. 31 (4865). — In 1893 the eye was struck with a piece of 
metal which flew of as he was shoeing a horse ; this caused a 
traumatic cataract, for which he was treated here. Two years 
later the eye became blind, and has lately assumed a rusty 
colour, and in March, 1896, it became painful and was excised. 
The lens is in situ and uninjured. The iris and vitreous are 
very rusty in appearance. A fairly large-sized chip of metal is 
lying embedded in the ciliary body. The retina and choroid 
are in situ. 

No. 32 (162 O.P.). — About four years before excision 
patient (a woman, aged 34) received a blow in her left eye 
with a tumbler which was thrown. The eye has recently 
become inflamed, and, as there were signs of early sympathetic 
ophthalmia, it was removed. The globe is shrunken and the 
lens calcareous. Situated at the back of the globe in the 
orbital fat are two large pieces of glass which are encapsuled, 
this is partially dissected off so as to show the foreign bodies. 
These pieces have penetrated the eyeball and passed completely 
through it. (Specimen in spirit.) 

(Reported in Trans. Ophth. Soc, vol. xvii, 1897.) 



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508 DESCRIPTIVE CATALOGUE OF SPECIMENS 



SERIES I. — Subseries (E) — continued. 

No. 5 (4939). — Section of an eye which had been injured 
with lime several years ago. This had induced traumatic irido- 
cyclitis. The eye was excessively irritable. The anterior 
chamber is shallow, and there are numerous posterior synechias. 
The pupil is blocked. The retina forms an umbrella-shaped 
detachment with cysts developed in it. The subretinal space 
was full of coagulated albuminous material. 



Series I — Subseries (F) —continued. 

No. 39 (4585). — The lateral half of an eye of a female, 
aged 59, who twice underwent the operation of couching for 
cataract at the hands of "an Indian oculist " during the two 
months before excision. It has been blind and painful ever 
since. A good deal of pigmented deposit is seen on the back 
of the cornea. The anterior chamber is very deep. The dis- 
placed lens is lying against the detached retina, and really in 
the subretinal space. The retina retains its attachment only to 
the optic disc behind and to the ora serrata on one side in 
front. 

No. 40 (4650). — Section of the eye of a man, aged 68, who 
had a cataract extracted here in October, 1894, and afterwards 
could see 6/12. Six months later the sight became very dim, 
and an extensive detachment of the retina was visible. V. = 
hand -movement. T. — 2. The iris and cornea are in contact : no 
anterior chamber Aphakia. The retina and choroid are de- 
tached, but are held down at four places, these being the 
positions where vessels perforate the sclera; there are thus four 
balloon-shaped detachments- of the choroid and retina. Some 
of the ciliary nerves are seen stretching across the subchoroidal 
space. 

(Reported in Trans. Ophth. Soc, vol. xvi, 1896.) 

No. 41 (4625). — The lateral half of the left eye of a man, 
aged 20, who underwent iridectomy for chronic glaucoma. The 
eye immediately became painful and blind. There is no 



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IN THE HOSPITAL MUSEUM. 509 

anterior chamber. The retina and choroid are both entirely 
detached by an enormous subchoroidal haemorrhage. The 
ciliary vessels and nerves are seen stretching across the sub- 
choroidal space. 

(Reported in Trans. Ophth. Soc, vol. xvi, 1896.) 

No. 42 (4621).— The lateral half of the eye of a man who, 
nine weeks before excision, had iridectomy done (probably for 
glaucoma or iritis), shortly after an attack of rheumatic fever. 
The globe is shrunken. T. —3. There is a coloboma of the 
iris upwards, with the remains of lens matter and inflammatory 
products in it, and in the pupil. The retina is drawn forwards 
and detached, and there is some blood-clot outside this. The 
choroid is to a great extent detached ; on one side there is a 
large cavity left, which is divided by two bands stretching 
across it into three spaces. On the other side there are two 
smaller spaces. Microscopic examination shows that the walls 
of these are composed of delicate connective tissue, being 
evidently the much thickened lamina suprachoroidia. These 
cyst-like spaces have no endothelial lining. 

(Reported in Trans. Ophth. Soc, vol. xvi, 1896/) 

No. 43 (4855). — Lateral half of the eye of a man, aged 74, 
who had a cataract extracted elsewhere four months before 
excision. The eye has been very painful ever since that time. 
T. +. The anterior chamber is almost obliterated, the iris 
and cornea being in contact. There is a coloboma on one side, 
and the opposite pupillary edge of the iris is connected with the 
scar of the extraction wound by means of a cyclitic membrane, 
being formed partly of lens capsule. The vitreous is shrunken 
and degenerated. The retina and choroid are in situ. The 
optic disc is slightly cupped. 

No. 44 (4860). — Section of the eye of a woman, aged 47, 
who had iridectomy for glaucoma pei^formed two months before 
excision. The eye did not do well, and the scar bulged. 
T. +3. Cornea steamy. V. = hand-movement. A coloboma 
is seen upwards, and the iris here has been removed well up to 
the angle, but the lens has become displaced into the wound and 
is blocking the angle ao-ain and causing the scar to bulge. The 



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510 DESCRIPTIVE CATALOGUE OF SPECIMENS 

iris on the opposite side is adherent to the periphery of the 
cornea.. The vitreous is healthy, and the retina and choroid are 
in situ. The optic disc is deeply cupped. 

No. 45 (4981). — Section of the left eye of a woman, aged 82 
an inmate of a workhouse, who was suffering from cataract, 
complete in the left eye, and commencing in the right. She 
was in very fair health, aud the tension and projection were 
quite good. Eye slightly myopic. The extraction was uncom- 
plicated, but some soft matter was left. The eye did not do 
well, and remained soft and injected. It was removed on 
account of pain twelve days later. The iris and some lens 
matter is drawn towards the wound, which is flat. The angle 
of the anterior chamber on the side opposite the iridectomy is 
widely open. There is severe inflammation of the ciliary body, 
and much blood exuded into it. The retina and choroid form 
together large, balloon-shaped detachments, and the sub-retinal 
space thus left is filled with exudation containing a considerable 
amount of blood. Some exudation of- a similar nature is seen 
microscopically to be between the retina and choroid. 

) 
No. 46 (4839). — Section of the right eye of a child, aged 5, 
who during four years has had numerous operations for con- 
genital cataract. She developed glaucoma, and then the eye 
shrank. The eye is badly developed, but the cornea and scle- 
rotic are much thickened. The remains of the lens matter and 
capsule remain, but are thickened with inflammatory material ; 
the iris is also adherent to this. The retina is considerably 
detached, so also is the anterior part of the choroid. 

No. 47 (4623). — Section of the eye of a man, aged 74, 
whose right eye was operated on for cataract without iridectomy. 
A good deal of soft cortex was left behind, and this was subse- 
quently evacuated, and the capsule was needled. The eye, 
which at first had V. = 6/18 Ji, got painful, and the sight 
failed. T. + 2. Some blood is present in the anterior cham- 
ber. The pupillary edge of the iris is adherent to the capsule, 
and there is a bombe iris. The vitreous is fluid, and the retina 
and choroid are in situ; both of these structures, and also the 
ciliary body, show microscopically much inflammatory change. 



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IN THE HOSPITAL MUSEUM. 511 

No. 48 (5058). — Section of the eye of a very alcoholic 
man, who did well after an extraction three years ago. The 
capsule was then needled. The eye at once suppurated. The 
whole vitreous, extending as far forwards as the lens capsule, 
is purulent ; the retina is much thickened, and both it and the 
choroid are slightly detached. 

No. 49 (5104). — Section of the eye of a woman who under- 
went the operation of cataract extraction without complication. 
Shortly afterwards purulent infiltration commenced about the 
wound. The eye did not suppurate, but became quite blind 
and painful, and then shrank. The retina is entirely detached; 
the choroid is also detached, but not so completely. The 
ciliary nerves can be seen stretching across the subchoroidal 
space. 

No. 50 (5153). — The left eye of a man, aged 35, which 
had been operated upon for cataract 20 years previously. The 
eye did badly, and has lately been painful. T. -f. There is 
an enormous staphyloma at the upper ciliary region. The iris 
is extremely atrophied. The vitreous is degenerated, and con- 
tains blood. The retina and choroid are atrophied, but in situ. 

No. 51 (5151). — Eye of a man, aged 52, who was operated * 
upon for cataract (at which he lost vitreous) eight years before 
excision. The eye became painful after a blow two weeks 
before removal. Tension full. There is a coloboma of the 
iris on one side, the remaining iris being atrophied and adherent 
to the cornea. The lens is absent, but a considerable amount 
of lens matter remains in the capsule ; this has mostly been 
reformed since the extraction. There is an extensive, though 
shallow, detachment of the retina, on which are numerous 
haemorrhages. The vitreous is fibrous and degenerate. The 
optic disc is deeply cupped. 

No. 52 (4035). — The left eye of a man, aged 33, which 
had been operated elsewhere four years a §'° for glaucoma, 
The operation done was sclerotomy, the iris being left in the 
wound. There is an enormous cystoid scar at the upper part ; 
the much atrophied iris is seen adherent to its inner surface. 
VOL. XIV. 2"L 



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512 DESCRIPTIVE CATALOGUE OF SPECIMENS 

The angle of the auterior chamber appears to be open on the 
opposite side. The lens is in situ, and the vitreous shrunken 
and detached. The eystoid scar is composed of vascularised 
fibrous tissue. The retina and choroid are in situ. 

No. 53 (2989).— Eye of a boy, aged 6, which was needled 
five years before removal, for cataract. This was followed by 
severe irido-cyclitis. Stretching across the iris is a dense 
cyclitic membrane. There is hardly any lens matter remaining. 
Covering the whole of the ciliary region and the adjacent 
choroid is a layer of inflammatory exudation ; the retina is 
somewhat drawn forwards in front, but is in situ behind. The 
choroid is much atrophied. 

No. 5 k (5104). — The eye of a woman, aged 63, which was 
operated on for cataract (extraction) a month before removal. 
The eye became infected, suppurated, and then shrank. The 
sclerotic is much puckered. The retina and choroid are both 
detached, and the ciliary vessels and nerves can be seen stretch- 
ing across the subchoroidal space. 

No. 55 (155 O.P.). — Eye of a woman who suffered from 
glaucoma, and for which iridectomy was done. The wound 
- became infected and bulged; the remains of the iris and ciliary 
body are seen to be prolapsed into the suppurating wound. 

No. 56 (5346). — The eye of a woman, aged 78, who had a 
cataract extracted with iridectomy nine months before excision. 
Iritis followed three months later. The iris is bombe, and 
adherent to a cyclitic membrane, which completely blocks the 
pupil. The retina and 7 choroid are in situ, and the fundus is 
healthy, 

Series II, 

Subseries (A) — continued — Inflammation following 
Ophthalmia. 

No. 40 (4320). — The lateral half of the eye of a man, 
aged 24, who had an attack of purulent ophthalmia, and lost 
the sight four years before excision. The globe was very 



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IN THE HOSPITAL MUSEUM. 513 

adherent to the orbital tissues; the cornea is thin, and shows 
many interesting microscopic changes in all parts (see Curator's 
Report). The anterior chamber is on one side, rather shallow, 
bat it is obliterated on the other side. The lens is shrunken, 
and there is a dense cyclitic membrane. The retina forms a 
cord stretching from the optic disc and then spreading out 
somewhat when it reaches the back of the lens ; one pro- 
cess stretches downwards, and has become adherent to the 
choroid. 

No. 41 (4609).— Lateral half of the eye of a man, aged 22, 
which was severely inflamed five years ago. A month before 
excision he had a blow, which caused it to become painful. 
The cornea is shown microscopically to be thickened and 
inflamed. The anterior chamber is deep, and contains a mass 
composed partly of crystals of cholesterine — it is apparently 
degenerated blood clot. The iris is very much thickened and 
retracted, and scarcely projects beyond the ciliary body, which 
is very much inflamed. The retina contains some cysts, and is 
completely detached, except at the optic disc. Both it and the 
choroid are so altered by cell infiltration, &c, that their struc- 
ture can barely be made out. 

No. 42 (5086). — Eye of a man, aged 74, who had suffered 
from ulceration of the cornea for three weeks ; the eye was 
cataractous and blind previous to this, and the coimea was very 
nebulous. The cornea is almost entirely destroyed, and the lens 
has escaped. The retina and choroid are adherent to each 
other and detached from the sclerotic ; a ciliary nerve can be 
seen running through the subchoroidal space. At various 
places the choroid is held in contact with the sclerotic by 
vessels and nerves which are entering and leaving the globe. 
It is impossible to be sure whether the choroid was or was 
not detached before the ulcer perforated. 

No. 43 (4942), — Section of an old inflamed eye, which had 
recently become very painful. T. -f 1. The iris is bombe. 
The lens is opaque, but in situ. The retina is completely 
detached from the optic disc to the ora serrata, and the sub- 
retinal space con* ains a quantity of cholesterine. 

2 l 2 



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514 DESCRIPTIVE CATALOGUE OP SPECIMENS 

No. 44 (5106). — Two eyes of the same patient, a boy, aged 
12, which had been affected since early infancy. Both being 
painful and blind, they were excised. 

(a) The right eye is represented only by a very much 
shrunken globe, which is solid throughout. The sclerotic is 
much thickened. The remains of the lens is calcareous, and 
there is some bone developed in the choroid. 

(6) The left eye is nothing like so much shrunken. The 
anterior chamber is very deep, and contained a quantity of 
blood, which has now been removed. Covering the iris and 
pupil is a thick layer of organised lymph. The lens is sur- 
rounded by inflammatory material. The retina is entirely 
detached, and the choroid has numerous colloid nodules on it. 
The sub-retinal space contained a quantity of cholesterine. 

No. 45 (5110). — Eye of a child, aged 9 years, who suffered 
in infancy from ophthalmia neonatorum. It had recently 
become inflamed, and painful. The cornea is opaque, and the 
remains of the greatly atrophied iris is adherent to it. Imme- 
diately behind this (in the place where the lens should be) is 
a mass of inflammatory exudation, which extends backwards to 
the ciliary body and vitreous. The vitreous itself is shrunken, 
and the hyaloid membrane detached. The retina and choroid 
are inflamed but in situ. 

No. 46 (5143). — Eye of a child, aged 3 \ years, who had 
suffered from extensive ulceration of the cornea six months 
before excision. The cornea and iris form a large anterior 
staphyloma. The lens is in situ, but stretching from its ante- 
rior surface to the staphyloma is a thin thread, which marks 
the centre of an anterior polar cataract, thus showing how it 
was formed; this synechia is 4 mm. long. The vitreous is 
healthy, and the retina and choroid show no naked eye changes, 
though inflammatory changes are visible microscopically. 

No. 47 (2974). — Eye of a man, aged 70, which was lost four 
years before excision as the result of <c a cold," (probably a 
perforated ulcer). The eye is puckered and flattened from 
before backwards. The retina and choroid are both detached, 
and the subchoroidal space is filled with dense whitish opaque 



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IN THE HOSPITAL MUSEUM. 515 

tissue, which is seen to consist microscopically of fine con- 
nective tissue and coagulated fibrinous material. 

No. 48 (5218).— Eye of a boy, aged 3| years. The cornea 
has been entirely destroyed by ulceration. The vitreous and 
lens are absent. The retina and choroid are entirely detached, 
leaving the sclerotic bare. The posterior ciliary vessels and 
nerves are seen stretching across the subchoroidal space. 

No. 49 (5261).— Eye of a girl, aged 15, who suffered from 
ophthalmia and ulceration of the cornea for 17 days. At the 
inner side of the cornea there is a large perforation with a 
prolapse of the iris and ciliary body. The lens is in situ and 
the back part of the eye is healthy. 

SERIES II. — Subseries (B) — continued, — Febrile Disease. 

No. 28 (4414).— The lateral half of the eye of a girl, aged 8. 
The eye had been blind for four years, following an attack of 
whooping cough. It again became infiamed two weeks before 
excision. There is a large anterior and ciliary staphyloma, the 
apex of which has perforated. The lens has escaped. The 
vitreous chamber is filled with pus and organised lymph, which 
is more dense at the front and lateral parts than behind. 
There are numerous retinal hemorrhages ; the retina itself is 
thickened and slight]y detached, except at the optic disc. 

No. 29 (4554).— Both halves of the left eye of a girl, 
aged 20. The sight Avas lost after an attack of measles which 
occurred in infancy. In one preparation the lateral half is 
shown. The cornea is very much thickened, and the iris, 
which is excessively atrophied, is adherent to its posterior 
surface, the two together forming an anterior staphyloma, 
which is nearly as large as the rest of the eye. The lens 
is situated at about the junction of the anterior and middle 
thirds of the globe. The retina is in situ, but there are many 
patches of retino-choroiditis at different parts of the fundus. 
The other preparation shows the condition at the ciliary region. 
The suspensory ligament is enormously stretched, and when 
held up to the light the condition resembles a spider's web. 



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516 DESCRIPTIVE CATALOGUE. OF SPECIMENS 

No. 29a (4632). — Half the ciliary region and lens of the 
right eye of a female, aged 23. The eye had been blind since 
infancy. The cortex and nucleus of the lens are shown, to- 
gether with the ciliary processes and suspensory ligament. 

No. 30 (4572). — Lateral half of the eye of a baby, aged 
3 months. Five days before excision the eye became inflamed 
and the lids swollen. It had convulsions during the night, 
and appeared to be in pain. When the eye was removed there 
was every sign of commencing orbital cellulitis. On removal 
there was found to be no pus in the orbit. The pupil was quite 
blocked. On section the globe is seen to be suppurating 
throughout ; the optic nerve is swollen ; the retina is very 
thick and detached, and there is much pus both in the vitreous 
and also in the subretinal space. 

No. 31 (4452). — Section of the eye of a man, aged 64, who 
had an attack of erysipelas four years before excision. It then, 
became blind, and he has had several attacks of kerato-iritis 
since. The eye was very soft, and the cornea small and opaque. 
The anterior chamber is shallow, and contains some blood. 
The lens is displaced somewhat laterally. The vitreous chamber 
is contracted, but it is filled with blood clot. The retina is de- 
tached from the optic disc to the ora serrata, and the subretinal 
space contains a quantity of altered blood clot. 

No. 32 (4580). — Section of the eye of a child, aged 8 weeks, 
who appeared to have glioma of both eyes. This eye (the left) 
was excised. The anterior chamber is yotj deep, but the angle 
is narrowed. The iris is shrunken and atrophied. The retina 
is detached and reaches from the lens to the optic disc. Micro- 
scopically the angle is seen to be quite closed, and the ciliary- 
body is drawn out of position by the shrinking retina. There 
is some inflammatory exudation connecting these two structures, 
and some haemorrhage in it. The retina is infiltrated through- 
out with small round cells. 

No. 33 (4451). — Section of the eye of a child, aged 18 months. 
About a week before excision it became inflamed. Previous 
to this it w r as supposed to be healthy. The retina is entirely 



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IN THE HOSPITAL MUSEUM. 517 

detached from the optic disc to the ora serrata. The 
lens is quite clear, and the su.bretiu.al space is filled with 
coagulated albuminous material. The choroid is in situ, and 
much marked with old patches of choroiditis. Microscopically 
inflammatory changes are seen, and at a point, just behind 
and to one side of the lens, there is a cyst developed in the 
retina. 

No. 34 (5073). — Section of the right eye of a child, aged 5 
years, which was noticed to be defective for five weeks. A dull 
reflex was seen, and the appearance suggested glioma. T. +. 
The section shows that the anterior chamber is deej) and the 
lens in situ. The retina is completely detached from the optic 
disc to the ora serrata, and some cysts are developed in it. 
The choroid is thin and shows marked inflammatory changes. 

No. 35 (4237). — Section of the eye of a girl, aged 13, which 
was lost nine years previously, after measles. There is no 
anterior chamber. The lens is calcareous. The retina is 
fibrous and forms large bands of tissue running more or less 
in the antero-posterior direction. 

No. 36 (4853). — Remains of the eye of a child, aged 3, 
who has recently suffered from measles and otorrhcea. The 
cornea is quite destroyed, and the contents of the globe, which 
is suppurating, are protruding through the necrosed tissue. 
Some orbital tissue has been removed, and this is quite dense 
and hard, as the result of inflammatory exudation. 

No. 37 (52S2). — Right eye of a child, aged 2|, which was 
first noticed to be affected eight months ago. The pupil when 
seen was dilated, and a white mass, with reddish areas like 
small haemorrhages, was seen. T. -f. The left eye was un- 
affected, — glioma was diagnosed. The cornea is clear and the 
anterior chamber is deep. Pupil dilated. Lens in situ. The 
angle of the anterior chamber is closed. The retina is entirely 
detached from the optic disc to the ora serrata and forms a 
cord running from before backwards. The subretinal space 
was filled with dense coagulated material. 



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518 DESCRIPTIVE CATALOGUE OF SPECIMENS 

No. 38 (5306).— Eye of a child aged 7 weeks, which had the 
appearance of a glioma. The tension was slightly increased. 
The anterior is about normal in depth, but the angle is 
closed by adhesion of the periphery of the iris to the cornea. 
The lens is in situ. The retina is completely detached from 
the optic disc to the back of the lens, and vessels are seen 
in it as well as several cysts. The choroid is much atrophied 
and the subchoroidal space is filled with coagulated albuminous 
material. 

(Reported in Trans. Ophth. Soc, 1898.) 

SERIES II. — Subseries (C) — continued. — Tubercular. 

No. 8 (4530).— The lateral half of the eye of a boy, aged 
2 years, which had been inflamed for six weeks'. There is a 
doubtful history of phthisis on the mother's side, but a very 
strong history on the father's side. No evidence or history 
whatever of syphilis. The cornea is clear, but the pupil is dis- 
placed and fixed. The cavity of the globe is divided into parts 
by a septum, and in the centre of each there is more or less of a 
space containing a quantity of semi-purulent broken-down 
material; the walls are composed of a thick gelatinous sort of 
material, and in it is probably the remains of the retina and 
choroid. Microscopic examination shows that the iris and 
ciliary body are very much inflamed and infiltrated, as also is 
the lens. The mass occupying the interior of the globe is com- 
posed of small round cells in a fibrinous ground substance, and 
numerous giant cells which have many nuclei arranged around 
the periphery of the cell ; around this are a few epithelial cells 
and thin masses of small round cells outside these again ; there 
are many of these more or less complete tubercle systems. The 
internal part is very degenerate, and scarcely takes the log- 
wood stain at all. 

(Reported in Trans. Ophth. Soc, vol. xv, 1895.) 

No. 9 (4666).— The lateral half of the eye of a child, aged 
1 7 months. She has been treated for pulmonary tuberculosis, 
and there is a strong family history of tuberculosis on the 
father's side. The cornea and lens are clear. The retina is 



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IN THE HOSPITAL MUSEUM: 519 

completely detached, but at the posterior pole there is. a large, 
firm, yellowish- white mass. 

Microscopic Examination. — The iris is much atrophied and 
there is well marked ectropion of the uveal pigment, both it 
and the ciliary body being much inflamed. The choroid is sepa- 
rated from the sclera in parts by fibrinous exudation ; it is 
much inflamed ; it runs into the large mass at the back, which 
is chiefly composed of large round and spindle cells, together 
with a good many giant cells. The central portion of the mass 
is degenerate, and does not stain well with logwood. The 
posterior part of the retina is involved in this mass, and the 
rest of it, although detached, is not much altered in structure. 

No. 10 (166 O.P.). — Section of the eye of a very feeble 
child, aged 8 months, which had been inflamed for a few weeks. 
Growing from the iris and occupying the anterior chamber 
is a cheesy looking mass which has perforated the sclerotic, 
and forms k ciliary and corneal staphyloma. Microscopically 
it is seen tofbe composed of typical tubercular tissue. 

(Reported in Oplifch. Soc. Trans., vol. xvii, 1897.) 

SERIES II. — Subseries (D) — continued, — Syphilitic. 

No. 16 (4341). — The lateral half of the eye of a man, aged 
24, who was the subject of inherited syphilis, and had suffered 
from interstitial keratitis. The cornea is opaque, bulged and 
vascular. The anterior chamber is obliterated. There is a colo- 
boma on on/3 side, but the stump of the iris remains. The lens 
is pressed forwards, and is almost in contact with the cornea. 
The ciliaryj processes are compressed, and the retina and choroid 
are thin arid atrophied. The optic disc was slightly cupped. 

"No. 1? (144 O.P.). — Specimen presented by Mr. J. R,. 
Lunn. T|he eye was from a man who suffered from irido- 
cyclitis, pbobably of syphilitic origin. The anterior chamber is 
very deer] (7 mm.), and was full of a thick, semi-opaque, 
gelatinous} material. The tension was +1. The iris and lens 
are driver! back. The vitreous is opaque. The retina and 
choroid are both somewhat detached, 



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520 DESCRIPTIVE CATALOGUE OF SPECIMENS 

No. 18 (5106).— Eye of a girl, aged 14, who had an attack 
of interstitial keratitis seven years ago. The eyes have heen red 
and inflamed off and on ever since. She has typical signs of 
congenital syphilis. The eyeball is much enlarged ; the antero- 
posterior diameter is 33*5 mm., transverse 26 mm. The cornea, 
which measures 16 mm., is opaque, and the iris is in contact 
with it for a large part of its extent. The lens is in situ and 
the vitreous degenerated. There are several patches of retino- 
choroiditis scattered over the fundus. The optic disc is not 
cupped. 

Series II. — Sub series (E) — continued. — Sympathetic. 

No. 14 (4384).— The lateral half of the eye of a patient who 
was suffering from sympathetic trouble in the other eye on 
account of cyclitis in this one. There are no further details of 
the history obtainable. The cornea is thickened and the 
anterior chamber full of coagulated material. Microscopically 
the angle of the anterior chamber is seen to be closed by 
adhesion of the root of the iris to the cornea^ the pupil 
is occluded by lymph ; the iris being greatly atrophied. The 
ciliary body and ciliary processes are infiltrated / with small 
round cells, and the whole of the vitreous chamber is filled with 
old blood clot. The retina is in situ, and the optic disc is 
slightly cupped. 

No. 15 (3343). — Section of the eye of a girl which was 
affected probably with a perforated ulcer in infancy. Shortly 
after its removal sympathetic ophthalmia developed in the 
other eye. The eyeball is disorganised and is almost solid, as 
the result of inflammatory mischief. The lens is opaque and 
shrunken. 

No. 16 (3343). — Eye of a woman which suffered from sym- 
pathetic ophthalmitis following cataract extraction in the 
other eye and subsequent iritis. This eye became involved two 
months after the primary operation : it was then excised. The 
cornea, iri.«, and lens are all matted together. The retina is 
entirely detached, and is lying as a cord between the.' optic disc 



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IN THE HOSPITAL MUSEUM. 52 L 

and the back of the lens. The subretinal space was filled with 
coagulated albuminous material. 

Series III. 

Subseries (A) — continued. — Primary Glaucoma in Adults, 

No. 19 (4619).— Lateral half of an eye for which iridectomy 
for glaucoma was done three months before excision, after a 
preliminary scleral puncture. The eye remained irritable and 
the iris more and more drawn up into a large cystoid scar. 
There had lately been much pain. T. + 2. There is a large 
bulged cystoid scar, to which the pupil is drawn. The lens is 
dislocated and is lying obliquely, one edge being tilted upwards 
and forwards; it is pushed right up into the bulged cicatrix. 
Microscopic examination shows that the iris has not been 
removed up to the periphery, and therefore relief of tension 
was not obtained, in spite of there being a large cystoid scar. 

No. 20 (4611). — The lateral half of the eye of a female, 
aged 80, who had iridectomy for glaucoma performed seven 
years before excision. There have been many attacks of pain 
since that time ; the eye has been more or less blind for 15 years. 
T. — . The cornea is flat, opaque, and vascular, and there is no 
anterior chamber, the iris being in contact with the cornea. 
The lens is opaque. The vitreous is detached, and forms an 
umbrella-shaped mass ; there is some blood in the space beneath 
this. There is extensive retino-choroiditis. 

No. 21 (3924). — Dissection of an eye which was removed on 
account of pain, after having been rendered blind by chronic 
glaucoma. The portion of the periphery of the iris which was 
in contact with the cornea is well seen. The pupil is slightly 
eccentric. 

No. 22 (4960). — Section of a blind eye which was excised in 
a state of acute glaucoma. The anterior chamber is very 
shallow and the pupil semi-dilated; the angle is blocked by 
adhesion of the iris to the back of the cornea. The optic disc 
is deeply cupped. The retina and choroid are in situ. 



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522 DESCRIPTIVE CATALOGUE OF SPECIMENS 

No. 23 (5010). — The eye of a woman which had absolute 
glaucoma. There is no anterior chamber, the iris, lens, and 
cornea being in contact. There is a deep glaucoma cup, and 
the fundus is covered with haemorrhages. The eye is myopic. 

No. 24 (92 O. P.).— Section of the eye of a person who 
suffered from absolute glaucoma. The iris is much atrophied, 
and is adherent to the cornea. The lens is somewhat displaced / 

and pushed up in close contact with the iris. The optic disc is / 

deeply cupped. The retina and choroid are not obviously 
affected. f 

No. 25. — Dissection of the eye of a gentleman which was 
excised as being blind and painful. The iris is much atrophied, 
and at the periphery it is seen to be flattened where it was in 
contact with the cornea. A portion of the iris has been removed, 
so as to show the lens somewhat displaced. 

SERIES III. — Subseries (B) — continued. — Secondary 
Glaucoma in Adults. 

No. 18/(4352).— Lateral half of the left eye of a female 
aged 60. The sight failed and the eye became painful 
three years previous to excision ; it quieted, but again became 
painful. .T. -f. The cornea is opaque, and microscopically 
it more resembles ordinary fibrous tissue than cornea. The 
lens is lying in the anterior chamber; the iris, which is atro- 
phied, is behind the lens. The retina is detached from the 
optic disc to the ora serrata. 

No. 19 (4340).— Lateral half of the left -eye of a female, 
aged 40. When first seen in January, 1894, this eye 
showed slight signs of glaucoma. E serine was put in and 
this produced acute glaucoma at once. Iridectomy was done 
upwards, and then it was discovered that the lens was slightly 
dislocated outwards. Tension again became high, and iridec- 
tomy was done inwards in April, 1894. It remained quiet, but 
on Jane 6 the right eye became dim, and, shortly afterwards, 
iritis and keratitis punctata developed ; this left eye was then 
excised. There is a scar at the upper and inner sclero- 



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IN THE HOSPITAL MUSEUM. 523 

corneal junction and a coloboma in this position. The lens 
is displaced somewhat outwards, pushed forwards and tilted 
so that the inner and upper part is lying almost in contact 
with the middle part of the cornea. Microscopic examina- 
tion shows that the iris Las torn, and that the root of it 
is left behind, and, therefore, the iridectomies were unsuccess- 
ful ; the angle on both sides is closed by adhesion of the root 
of the iris to the cornea. The vitreous is shrunken, and it is 
slightly infiltrated with small, round cells. The retina is in 
situ. The ciliary body is inflamed, and the optic disc is 
cupped. 

No. 20 (4583). — The lateral half of the eye of a man 
aged 34. The sight has been failing gradually for two years 
after a blow with a rivet. T. +. Eye frequently inflamed. 
An iridectomy has been done upwards, and the lens, which 
is opaque, is displaced and is lying close against the scar of 
the iridectomy wound. The retina is completely detached, 
and is lying as a cord stretched between the optic disc and 
the back of the lens ; a cyst is seen in it. There is a blood 
clot lying in the subretinal space. 

No. 21 (4216). — Lateral half of the eye of a woman, aged 
31. She had a severe blow on the right eye three years 
before excision, and since then she has not seen well with it. 
It suddenly became painful eight weeks ago. There is a very 
deep anterior chamber, and this is almost entirely occupied 
with the displaced lens, on which there is some plastic exuda- 
tion. On one side the iris is folded backwards, and on the 
other side it is lying stretched behind the lens. The angle 
of the anterior chamber is closed by adhesion of the iris to 
the cornea. The optic disc is deeply cupped. 

No. 22 (4259). — The lateral half of the right eye of a man, 
aged 31. Twenty years ago the eye was injured by a blow 
from a tip-cat. It remained quiet until -five days ago when 
he was kicked in it, since then it has been painful. The 
anterior chamber is shallow, and the angle is closed on both 
sides. The pupil is dilated and the iris is shrunken, with 
much ectropion of the uveal pigment. The lens is somewhat 



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521 DESCRIPTIVE OA.TA.LOGKJE OE SPECIMENS 

displaced. On the anterior surface of the lens there is a pro- 
jecting portion, having a circular outline, as though moulded 
by pressure against the pupillary margin of the iris. The 
retina is detached from the optic disc to the ora serrata, and 
contains numerous microscopic cysts. The choroidal vessels 
are well seen. 

(Reported in Ophth. Soc. Trans., vol. xiv, p. 140.) 

No. 23 (4208).— The lateral half of the eye of a man 
which was accidentally found to be blind seven years before 
excision. The iris is much shrunken, and the pupil is widely 
dilated. The anterior surface of the lens is moulded by 
pressure. 

(Reported in Ophth. Soc. Trans., vol. xiv, p. 139.) 

No. 24 (4811). — Vertical section of the eye of a woman 
ao-ed 68, who had a cataract extracted 10 weeks before ex- 
cision. The eye, after having done well, subsequently be- 
came inflamed, painful and glaucomatous. The cornea was 
h.izy, and the anterior chamber deep. There is much lymph 
and lens matter in the pupil ; the capsule is adherent to the 
scar and is dragged forward in the wound. The vitreous is 
degenerated and very fluid. The choroid and retina are in 
sitUy and not obviously affected. 

No. 25 (4838). — Section of the eye of a woman, aged 30, 
which became affected seven weeks before excision. T. +3. 
The angle of the anterior chamber is closed on both sides and 
the pupil is adherent to the lens capsule, probably by in- 
flammatory exudation : the same material can be seen at the 
lower part of the chamber. The fundus is covered with 
haemorrhages. 

No. 26 (3853). — The eye of a man who was injured 60 
years before excision with a stone. The globe is much 
enlarged. The iris, which is extremely atrophied, is adherent 
to the cornea at its periphery, and also to the old corneal 
wound forming an anterior synechia. The lens is absent. 
The vitreous is degenerated, and the whole fundus is a mass 
of re tino- choroiditis. 



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IS THE H3SPITAL MUSEUM. 525 

No. 27 (5141). — Section of the right eye of a woman, aged 
39, which had gradually been failing for 20 years, but with- 
out pain. T. +1. The anterior chamber was entirely occu- 
pied by the lens, which has now fallen out, and the angle is 
closed. The vitreous is degenerated. The retina and choroid 
are thin and atrophied. The optic disc is deeply cupped. 

No. 28 (4942). — Eye of a woman, aged 58, who suffered 
for many months from " inflammation " in it. The specimen 
is now much flattened on account of the impossibility of 
hardening it properly without losing the crystals. The retina 
is entirely detached, and the subretinal space contains much 
cholesterine. 

SERIES III. — Subseries C — (continued). — Glaucoma in 
Children. 

No. 11 (4508).— The lateral half of the eye of a girl, aged 6. 
When two weeks old she had an ulcer on the right eye. 
T. -f . Antero-posterior diameter 26 mm. Transverse 24 mm. 
The eye is much distended, the coats are thin, and there 
is a considerable bulging in the ciliary region. The iris is 
atrophied and adherent to the back of the cornea, the ciliary 
processes being much stretched ; the ciliary body is so thin 
that, even under the microscope, it can scarcely be seen. The 
lens is shrunken and calcareous. The retina and choroid are 
very atrophied, and the optic disc is deeply cupped. 

No. 12 (4355).— The lateral half of the eye of a girl aged 
17, who injured the left eye 11 years before with a fork 
while untying a boot-lace. The eye had been blind ever 
since. T. +2. Antero-posterior diameter 81 mm. Transverse 
27 mm. Width of cornea 18*5 mm. Depth of anterior chamber 
in its middle 3'4 mm. The angle of the anterior chamber is 
closed by adhesion of the cornea to the iris for a distance of 
3'5 mm. at the periphery. The iris is much thinned, the 
pupil is dilated, and there is some ectropion of the uveal 
pigment. The posterior chamber is very deep (4 mm.), and 
there is a tag of uveal pigment stretching across from the 
iris to the anterior capsule of the lens. The lens is repre- 



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526 DESCRIPTIVE CATALOGUE OF SPECIMENS 

sented by a circular mass of lens matter with a diaphragm 
across the centre like a circular water-cushion. This dia- 
phragm is opaque and consists of the anterior and posterior 
lens capsules which are adherent. The suspensory ligament is 
thickened by inflammatory deposits on it, the vitreous is 
degenerated, and the retina is in situ. The pigment layer is 
almost entirely absent, and the choroid is atrophied. The 
optic disc is deeply cupped. 

Series IV. 

Sub series (B) — continued. 

No. 8 (4720). — Portion of the eye of a man, aged 50, who 
had been suffering from rodent ulcer of the lid for some 
years. The eyeball became affected with a hypopyon ulcer, and 
was removed, together with the adjacent affected conjunctiva. 
A large mass of conjunctiva containing much inflammatory 
exudation and some new growth is seen overlapping the cornea. 
This is ulcerated, and some lymph is seen in the anterior 
chamber. . 

Series IV. — Subseries (D) — continued. 

ISTo. 15 (4782). — Portion of the eye of a woman, aged 32, 
the sight of which had been failing for six months. T. — 1. 

The retina is entirely detached, and the subretinal space is 
partly occupied with a very deeply pigmented growth, which is 
springing from the ciliary body and the adjacent choroid. It 
has a broad base, and a constriction where it has apparently 
burst through the elastic lamina. The rest of the subretinal 
space is filled with dense coagulated albuminous material. The 
anterior chamber is very shallow, but the angle is open ; there 
had never been any increase of tension. 

No. 16 (4765). — Lateral half of the left eye of a woman, 
aged 60, who had noticed the sight failing for about five 
months. It had never been painful nor had she suffered from 
glaucomatous symptoms. T. normal. 

The anterior part of the eye is healthy. Situated in the 
ciliary region and immediately behind the lens (which is in- 



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IN THE HOSPITAL MUSEUM. 527 

dented by it) is a large unpigmented sarcoma. It extends 
backwards to well behind the equator. 

The retina is detached over the tumour and also to a slight 
extent behind it; the subchoroidal space is here filled with 
some coagulated material. The rest of the retina is in situ. 
The growth is composed of small round cells, with a slight 
tendency with some of them to become spindle-shaped. It is 
not very vascular, but a few vessels run through it. An 
isolated pigment cell is here and there seen in the section, but 
the growth is essentially unpigmented. 

No. 17 (4779). — Lateral half of the left eye of a woman, 
aged 70, who has noticed the sight failing for two months. 

The eye was blind and painful. T. + 3. 

The anterior chamber is very shallow. The lens is dis- 
placed much to one side by means of a large and deeply pig- 
mented growth, which extends from the iris to within 1*5 mm. 
from the optic nerve. 

The retina covers the mass, and is elsewhere in situ, except 
at the posterior part of the growth, where it is slightly sepa- 
rated from the choroid by some jelly-like exudation. It is 
very vascular and deeply pigmented, and composed of round 
and a few spindle cells. 

No. 18 (4748). — Antero-posterior section of the eye of a 
woman, aged 64, who had noticed the sight failing for three 
months. 

T — . The cornea is clear and the anterior chamber 
shallow. Occupying rather more than a third of the globe is 
a very deeply pigmented melanotic growth. The retina is 
entirely detached over it, and it reaches from the iris in front 
to nearly as far as the optic nerve behind. 

No. 19 (4561). — Lateral half of the eye of a woman, aged 
61. The vision was normal, but it was found accidentally that 
there was a growth in the ciliary region. Microscopically it is 
seen to be a sarcoma, whiclijs almost devoid of pigment in 
some parte, though at other places it is somewhat deeply 
pigmented. 

The greater part of the growth is hollowed out into a 
VOL. XIV. 2 M 



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528 DESCRIPTIVE CATALOGUE OF SPECIMENS 

large cystic space which does not contain an endothelial lining. 
There are numerous smaller cystic spaces in the more solid 
part of the growth. The choroid is stretched over it, and the 
retina has been removed. The patches seen in choroid are post 
mortem. 

(Reported in Ophth. Soc. Trans., vol. xv, 1895.) 

No. 20 (4844). — Lateral half of the eye of a woman, aged 
55, whose left eye had become misty about four months ago. 

T. 4- 1. In the anterior chamber on one side is a slight 
bulging, and this corresponds to a small solid tumour which is 
situated in the ciliary body close behind the iris ; it is about the 
size of a split pea ; it is deeply pigmented, Microscopically it 
is seen to be a melanotic sarcoma. 

No. 21 (139 O.P.). — Lateral half of an eye removed for 
sarcoma. There is a fairly large growth in the choroid, and 
the ciliary body is just affected. Before the eye was removed 
the tension was — 1. The angle of the anterior chamber is 
open. 

No. 22 (4991). — Eye of a man, aged 61, who had noticed 
the sight failing for five weeks. T. — 1, The cornea is clear 
and the angle of the anterior chamber is open. Situated 
beneath the choroid, and extending from the ciliary body to 
somewhat beyond the equator, is a large mottled growth. 
Microscopically it is seen to he a sarcoma, having pigment 
scattered sparingly through its substance. The choroid else- 
where is in situ, but the retina is extensively detached by means 
of coagulated albuminous material which is beneath it. 

No. 23 (5232).— Eye oi a man aged 28. The sight began 
to fail about six months previously, and a detached retina was 
seen four months before excision. Four days before removal 
the eye became suddenly painful, T. + 2, with all the signs of 
acute glaucoma. 

The angle of the anterior chamber was quite closed, and the 
cornea steamy. The retina is entirely detached, and the sub- 
retinal space was filled with blood. Growing from the choroid ? 
and slightly encroaching on the ciliary region, is a deeply pig- 



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IN THE HOSPITAL MUSEUM- 529 

mented sarcoma. The detached retina is seen in the section 
lying on the growth. 

No. 24 (164 O.P.).— The eye of a patient which was 
removed by Mr. W. Sinclair, of Ipswich. The anterior cham- 
ber is normal, and the angle is open. Growing from the choroid 
and extending from the ciliary body in front to within 7 mm. 
of the optic nerve behind, is a large mottled pigmented sar- 
coma. The retina is extensively detached by means of some 
coagulated albuminous material, which has now been removed. 
Tension normal, 

No. 25 (4684). — Eye of a woman, aged 74, which had been 
defective for an indefinite time. It has lately been painful. 
The anterior chamber is extremely shallow and almost oblite- 
rated. Growing from the ciliary body, and involving the neigh- 
bouring iris and choroid, is a large and very black sarcoma. 
The lens is much displaced by the growth. Patient died 21 
months after the excision from " inflammation of the kidneys." 

No. 26 (192 O.P.).— Eye which had recently become painful 
and glaucomatous. The anterior chamber is obliterated. Ten- 
sion + 2, There is a very large, slightly pigmented sarcoma 
reaching from the ciliary body nearly to the optic disc. The 
retina is complete!)' detached. 

No. 27 (5309), — Eye of a woman, aged 60, whose sight 
had been failing for about a year. She was admitted with 
.acute glaucoma, and the eye was at once excised. 

The angle of the anterior chamber is closed and the retina 
detached. There is a diffuse sarcoma at the back of the eye ; a. 
nodule of growth is seen ontside the sclerotic, and this can be 
traced microscopically through the sclera. 

Series IV — Subseries (E) — continued, 

No. 42 (4456).— Lateral half of the R. eye of a woman 
whose sight had been failing for three years from detachment 
of the retina. For three weeks before it was excised it had 
been very painful and glaucomatous. There is an extensive 
detachment of the retina. Occupying a large area at the back 

2 m 2 



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530 DESCRIPTIVE CATALOGUE OF SPECIMENS 

of the P-lobe and beneath the retina is a flattened melanotic 

o ■ ■ 

growth; this has come through the sclerotic at the place 
where the posterior ciliary vessels penetrate. Outside the scle- 
rotic the growth is about three times as large as the part 
within, but it is not so deeply pigmented. The subretinal 
space was filled with a quantity of coagulated jelly-like mate- 
rial. Microscopic examination shows the growth to be a mela- 
notic sarcoma. Patient died five months later of secondary 
growths, 

No. 43 (75 0. P.). —Lateral half of the eye of a man whicli 
was excised on account of pain following glaucoma with detach- 
ment of the retina. 

Situated at the back of the eye and beneath the retina is a 
large growth surrounding the entrance of the optic nerve and 
a considerable area on both sides, of this. The retina is entirely 
detached, and the subretinal space was filled with very hard 
gelatinous material ; the patches seen on the choroid were 
caused by adhesions between these two. The growth is shown 
by microscopic examination to. be a sarcoma containing nume- 
rous large vessels ; it is almost entirely devoid of pigment. 

No. 44 (59 O.P.).— Portion of an eye of a man, aged 40, 
the sight of which had failed during a few weeks before 
, removal. 

The retina is detached at all places except at the optic disc 
and ora serrata. There is a growth situated at the yellow spot 
region beneath the choroid. It is entirely unpigmented, and. is 
composed of small round and spindle cells. 

(Specimen presented by Mr. Rockliif e.) 

~Ro. 45 (4481). — Lateral half of the eye of a man who had 
noticed the sight failing for about six months. The outside 
growth appeared 10 days before excision. The whole of the 
o-lobe is entirely filled with a melanotic sarcoma, which has 
found its way through the sclerotic at the positio3,i where one of 
the venas vprticosaa perforate it. The mass outside is nothing 
like so deeply pigmented as that within the globe. 

(Reported in Ophth. Soc, Trans., vol. xv, 1895, by Hodges 
and Ridley.) 



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IN TEE HOSPITAL MUSEUM, 531 

No. 46 (4515).— Section of the eye of a child, aged 3. A 
white spot had been noticed in the pupil for two years. 

The whole globe is filled with a soft tumour, which varies 
somewhat in appearance in different parts. 

The choroid is entirely detached, and the most actively 
growing part is attached to its outer side, between it and the 
sclerotic. The vitreous chamber is filled with new growth, but 
here it is to a certain extent degenerated and broken down. 
Pigment stretches from the choroid into the mass outside it. 
The optic nerve is extensively involved. 

Microscopically the growth consists almost entirely of small 
round cells with hardly any ground substance. 

Many of the cells are much degenerated, while others stain 
well. In the region of the choroid there is a good deal of pig- 
ment scattered through the growth. It has more the structure 
of a sarcoma than of the ordinary glioma. 

The growth subsequently recurred and filled the whole 
orbit. 

No. 47 (4442). — Section of the eye of a man, aged 43, 
whose sight has gradually failed. . The front part of the eye 
is qaite healthy. Lying at the back of the globe and adjoin? 
ing the optic nerve is an unjoigmented sarcoma. It is beneath 
the choroid, and the retina is somewhat extensively detached,, 
though it was less detached than it is now. The sclerotic is 
very thin, and bulged, and is almost perforated by the growth. 

The tumour is seen microscopically to be a small round- 
celled sarcoma. 

ISTo. 48 (4795). — The right eye of a man, aged 71, who has 
known it to be blind for at least a year. It has been extremely 
painful for the last six weeks. The sight was good previous to 
this. 

T. -+- 3. Occupying nearly half of the interior of the 
globe, and projecting through an aperture in the sclerotic, is 
a large melanotic sarcoma. The middle part of the growth 
and that connected with the part outside the globe is much 
less pigmented than the rest. It is entirely covered by the 
retina, and is beneath and in the choroid. It reaches anteriorly 
to the lens and lies against one half of it ; posteriorly it reaches 
to within 10 mm. of the optic nerve. 



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532 DESCRIPTIVE CATALOGUE OF SPECIMEN'S 

No. 49 (4851).— Half of the left eye of a woman aged 37. 
The sight of this eye has been failing for a year and a half. 
For two months the eye has been almost completely blind. 
The tension was normal. 

The cornea is clear ; the anterior chamber is normal and the 
angle open. At the posterior part of the eye, and reaching 
from a point about 2 mm. from the optic disc to almost as far 
forward as the equator, is a deeply pigmented growth which 
shows a constriction in its middle. The retina is extensively 
detached. 

No. 50 (137 O.P.).— Portion of the eye of an adult which 
was excised for acute glaucoma. There is a mushroom-shaped 
melanotic sarcoma situated at the back part of the eye • the 
angle of the anterior chamber is closed, and the retina is 
detached. The lens was in situ. 

No. 51 (5127). — Section of the left eye of a woman, aged 
67, whose sight had been failing for 18 months, but much 
more rapidly for the last six months. T. -f 1. The angle of 
the anterior chamber is closed. Filling about two-thirds of the 
globe is a darkly pigmented melanotic sarcoma. The retina is 
entirely detached, and part of it is seen stretching from the 
side of the lens to the tumour. 

No. 52 (5231).— Eye of a man, aged 56, who had noticed the 
sight of the left eye failing for nine months. On ophthalmo- 
scopic examination a large detachment of the retina was seen. 
The tension was — . On the diagnosis of a tumour being made 
the eye was excised. Externally the eye appeared healthy. 
The anterior chamber is of normal depth, and the angle is open. 
The lens is in situ. Growing from the choroid on one side is a 
mushroom-shaped melanotic sarcoma. The retina is detached 
over a much larger area than that occupied by the tumour. At 
no place did the tumour extend sufficiently far forwards to 
touch the ciliary processes. The unusual thing about this case 
was the tension, which was — , although the ciliary body was 
not involved. 

(Reported in Trans. Ophth. Soc, 1898.) 



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IN THE JIOStaTAL MUSEUM, 533 

No. 53 (5113). — Eye of a man, aged 57, who bad noticed the 
sight of the right eye failing three months. The eye was 
quiet and tension normal. The anterior chamber is somewhat 
shallow, but the angle is open. The lens is in situ. Situated 
at the posterior part of the eyeball, and extending from the 
edge of the optic nerve behind to the equator in front, is a 
large oval-shaped melanotic sarcoma. Its section has a mottled 
appearance. The retina was niuch more extensively detached 
than now appears, owing to a quantity of coagulated albumin- 
ous material which was beneath it. 

No. 54 (147 O.P.). — The eye of a lady, which was removed 
on account of the presence of a tumour. She had been operated 
upon two years ago for scirrhus of the breast. She died 
shortly after the eye was excised from recurrent growths in 
the abdomen. The cornea is clear, and the anterior chamber 
shallow. The lens is in situ. The retina is extensively de- 
tached. Situated at the posterior part of the eye is a flattened 
growth, which extends from about 3 mm. on one side of the 
optic nerve to the equator on the opposite side ; it has a semi- 
opaque appearance, and is beneath the choroid, which can be 
seen running on its surface. The head of the optic nerve is 
involved. A quantity of coagulated albuminous material filled 
up the subretinal space. Microscopically the growth is seen to 
be a glandular carcinoma having a structure similar to that of 
a cancer of the breast, of which this is a metastatic growth. 

(Published in Ophth. Hos. Report, vol. xiv, pt. 3.) 



Series IV — Subseries (F) — continued. — Glioma. 

No. 23 (4672),— The lateral half of the eye of a child, 
aged 1 year and 4 months, A white spot was first noticed in 
this eye four weeks before excision. It has increased much in 
size during the last week. 

Tension +. Cornea clear. Anterior chamber normal. 
Pupil semi-dilated. 

About four-fifths of the globe is filled with a large white 
solid growth. Numerous spots of degeneration are seen in it. 

The retina is completely detached, though on one side it can 



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534 DESCRIPTIVE CATALOGUE OF SPECIMENS 

be seen passing into the growth. The subretinal space was 
filled -with coagulated albuminous material. 

Microscopic examination shows that the root of the iris is 
adherent to the cornea; 

The mass is a glioma growing from the vitreous surface of 
the retina. 

No. 24 (4827). —Section of the eye of a child, agel 
6 months. A. white spot had been noticed for several weeks, but 
it had grown considerably late ly. Tension normal. The cornea 
is clear. The anterior chamber is of normal depth. The lens 
is clear. The retina is completely detached, and beneath it and 
growing from it is a large glioma. 

No. 25 (96 O.P.). —Section of the eye of a child,- aged 5|, 
who was under the care of Mr. Rockliffe, of Hull. The history 
is imperfect. The pupil is widely dilated, and the iris is 
atrophied. The retina is entirely detached, but growing from 
its inner side is a dense solid tumour; it reaches through the 
sclerotic and forms a mass lying at the back of the globe and 
to one side of the optic neiwe. The nerve and its sheath are 
much thickened and involved in the growth. The interior of 
the extraocular portion is more dense than the exterior, which 
is semi-transparent and gelatinous looking The subretinal 
space is filled with exudation, and the choroid is much atro- 
phied and slightly detached. Microscopically the tumour is 
seen to be a glioma.- 

No. 26 (4848).— Section of the left eye of a child, aged 2£. 
For the last eight months a white mass has been seen in it. 
Two months before excision an abscess of the cornea deve- 
loped. 

The eye is considerably enlarged. The cornea is opaque and 
the middle part is destroyed. The globe is solid throughout, 
but it varies somewhat in consistence. The part which repre- 
sents the vitreous chamber is a good deal shrunken, and 
contains a quantity of fairly dense, broken-down tissue of 
granular appearance. The rest of the globe is filled with a 
solid semi translucent growth. The sclerotic is perforated, and 
the mass extends well back into the orbit; there is a thin 



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IN THE HOSPITAL MUSEUM. 535 

capsule round it. The optic nerve is seen on one side, sur- 
rounded by the new growth, and infiltrated. Microscopic 
examination shows ifc to he a glioma, with very few vessels in 
it. (A later report says that the child is dying of recurrence 
in the socket, and the disease is manifest in the other eye.) 

No. 27 (77 0. P.).— Section of the eye of a child, aged 
15 months, which was excised for glioma. The retina is 
detached and unrecognisable ; the whole of: the snbretinal space 
is filled with a white neoplasm, which is a glioma. 

No. 28 (5123). — Section of the eye of a child, aged 2, in whose 
eye a white appearance had been noticed about nine months. 
Tension +. The angle of anterior chamber is quite closed. 
The lens is in situ. Growing* from the vitreous surface of the 
retina is a larger glioma. A process extends forwards exactly 
in the position of the hyaloid canal and terminates at the pos- 
terior surface of the lens forming a secondary growth in this 
situation. The optic nerve,- which is cut short, is involved. 

No. 29 (5083).— Section of the right eye of a child, aged 2, 
which was miich inflamed and had hemorrhage in the anterior 
chamber. There was much conjunctival irritation. On section, 
the lens is seen to be displaced backwards and to one side. 
The retina is unrecognisable, being entirely detached and in- 
volved in the tumour. The growth is a glioma, having 
numerous hard calcareous patches in ifc. Ifc is very greatly 
degenerated, and the optic nerve is extensively involved. 

No. 30. — Posterior half of an eye of a child, which was 
excised on account of the presence of a glioma. The growth 
has perforated the eye below, and has become extraorbital. 

No. 31 (5299).— Eye of a child aged 12 weeks. A white 
spot was noticed in the left eye eight weeks before removal. 
Tension +2. The anterior chamber and its angle are almost 
obliterated. The globe is two-thirds filled with a lai.ge glioma ; 
it has numerous areas of degeneration, and the remains of the 
retina can be seen running from the optic disc to the back of 
the lens. The choroid is much atrophied. 



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.536 DESCRIPTIVE CATALOGUE OF SPECIMENS 

No. 32 (170 and 190 O.P.).— Two eyes from the same 
patient, a child, aged 2. The left was removed two months 
before the right. The left was known to be affected since 
birth, the right a few days before removal. 

The left eye is almost full of growth, and this is breaking 
clown. The growth in the riglit eye is more solid, and springs 
from the outer surface of the retina. 

No. 33 (5319)* — Eye of a child, aged 5, whose R. eye was 
excised when she was four months old, 

Shortly after the L. was seen to be affected. The eye 
has gradually shrunk. As it was blind and painful it was 
removed. The lens is displaced and calcareous. The rest of 
the eye, which is much shrunken, is full of growth, which is 
seen microscopically to be a glioma. The ciliary body is 
greatly affected, and possibly to this is due the shrinking. 

(Reported in Ophth, Hosp. Reports, vol. xiv, pt. 3, p. 463.) 



Series V. 
Congenital Malformations of the Eye. 

Among the numerous congenital malformations to 
which the eye is subject, there are but few which can be 
shown as museum specimens, though examples of one or 
other variety are of frequent occurrence, and are by no 
mean uncommonly seen clinically, 

This description will be almost entirely confined to 
those conditions which are illustrated by specimens in the 
museum. 

Microphthalmos* 

This condition varies greatly in extent, and no sharp 
line of demarcation can be drawn between an eye which 
is highly hypermetropic and one which can definitely be 
termed microphthalmia In. extreme degrees the eye may 
be so minute as to be entirely missed unless carefully 
looked for, and many of these are wrongly classed as 
cases of anophthalmos. Although some eyes which may 



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IN T THE PIOSPITAL MUSEUM. 537 

be termed microphthalmia show no further change than 
that of being greatly diminished in size, yet it is by no 
means uncommon to find some other congenital pecu- 
liarity such as failure in the closure of a cleft leading to 
the formation of a coloboma of the choroid, iris, or nerve 
sheath. In other rare cases, cysts may develop in con- 
nection with the malformed eye (O.H.R., xii, p. 289); 
these cysts may be very much larger than the rudiment- 
ary eye, which is sometimes no larger than a hemp seed. 
They are caused by a weak or deficient sclera which 
leads to the formation of a staphylomatous bulging at a 
certain spot (Nos. 9, 10, 11). 

Buphthalmos. 

This is also known under the term congenital hydr- 
ophthalmos or congenital glaucoma. 

This is a somewhat rare condition, and the eye pre- 
sents a peculiar condition ; it is considerably enlarged in 
all directions. The cornea may attain a very large size, 
and all the coats of the eye are more or less thinned. 
The anterior chamber is, as a rule, deep, and the optic 
disc cupped (No. 8). 

All these changes are due to increased tension occur- 
ring in the young and elastic tissues of infancy, and the 
cause of the tension is the same as that met with in the 
glaucoma of later life, viz., the closure of the angle of the 
anterior chamber, and consequently the aqueous collect- 
ing in a more or less closed chamber leads to its becoming 
deep instead of shallow. 

Orbit. 

The congenital abnormalities affecting the orbit are 
few. Dermoid tumours are occasionally found, but these 
are rare. V 

The orbits themselves maybe undeveloped or so small 
that they will not hold the eye at all. The appearance 
produced is that of great propf osis. 



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538 DESCRIPTIVE CATALOGUE OF SPECIMENS 

Conjunctiva. 

The most common form of congenital affection of the 
conjunctiva is a dermoid tumour. Those which are 
superficial nearly always occur at the corneoscleral 
margin and overlap both structures to a greater or less 
extent. The deeper ones are mentioned in connection 
with the orbit, as they do not strictly belong to the con- 
junctiva. 

Fibrofatty growths of a congenital nature are some- 
times seen beneath the conjunctiva, and may, if large, 
project between the eyelids. 

Cornea. 

There are numerous congenital peculiarities about the 
cornea. It is much diminished in size in cases of micr- 
ophthalmos (No. 9)i It is increased in size in cases of 
buphthalmos (No. 8). Occasionally congenital opacities 
are developed in it, and also a more or less wide arcus 
somewhat resembling an arcus senilis ; this is termed by 
Wilde arcus juvenilis. 

Conical cornea is held by some (Tweedy) to be the 
result of an imperfect development of the cornea which 
leads to a weakness and consequent bulging of its central 
part (Trans. Ophth. Soc, xii, p. 67). 

Congenital dermoid tumours are generally met with at 
the corneoscleral junction, and these may encroach to a 
great extent upon the cornea. They are mentioned 
under the head of congenital tumours of the conjunctiva. 
They frequently have hair bulbs in them, and these often 
begin to grow about the age of puberty, thus leading to 
considerable conjunctival irritation. Other very rare 
forms of dermoid growths are bands of skin running from 
the cornea to some part of the lid. Dermoid growths 
exactly corresponding to a coloboma of the lid are some- 
times found, and these cases are nearly always associated 
with some other congenital defect. 



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IN THE HOSPITAL MUSEUM. 



539 



• ' The iris is very liable to congenital defects and pecu- 
liarities. Defects or alterations in the pigment and its 
arrangements produce striking arid obvious results. 

Pigment is normally present in the epithelium lining 
the posterior surface of the iris, and in most cases it is also 
scattered through the stroma. The extent to which this 
latter is developed modifies the appearance of the eye. 
If there is little or none present, a blue colour is pro- 
duced, owing to the dark pigment at the posterior surface 
being seen through the vascular stroma. If it is more 
or less thickly scattered through it, the different shades 
of green, grey, and brown are produced. If again the 
pigment be altogether absent from the iris, it is always 
associated with absence of pigment in other parts, and 
the condition known as albinism is the result (Nos. 4 
and 7). 

When the pigment forms nodules at the pupillary edge 
or actually turns round the pupillary edge and forms a 
ring of pigment on the anterior surface of the iris, this is 
termed ectropion of the uveal pigment. It is more often 
seen as a pathological change in some cases of atrophy of 
the iris than as a congenital abnormality* 



x t> v 



Persistent Pupillary Membrane*. 

The pupillary membrane which is formed from the 
anterior fibro-vascular sheath of the lens should, under 
normal conditions, disappear completely before birth. It 
sometimes happens that some remains of it are left 
behind as fibres which arise usually from the anterior 
surface of the iris and" stretch across the pupil to the 
opposite side; sometimes they only project into the pupil 
without going right across, and occasionally a fibre may 
run from the iris to the back of the cornea (No. 3). 



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540 DESCRIPTIVE CATALOGUE OF SPECIMENS 

Irideecemia or Aniridia, 

Cases are occasionally seen in which no iris is visible 
clinically, even when the observer is aided by artificial 
light and the ophthalmoscope. These cases usually have 
a small ring of iris which cannot be seen until a section is 
made of the eye (No. 2). Owing to the close apposition 
of the rudimentary iris to the periphery of the cornea, such 
eyes may suffer from glaucoma. 

Coloboma of the Iris, 

^ A congenital coloboma of the iris is often associated 
with other congenital malformations both of the eye and 
of other parts. The usual position for it to occur is 
downwards with a slight inclination inwards. It may be 
so slight as to cause a notch only in the pupillary area, or 
it may extend down, or nearly down, to the root of the 
ins (No. 4). If unassociated with other defects, the sight 
may be unimpaired. 

Colobomata of the choroid and optic nerve sheath are 
not illustrated by any specimens in the museum. 

Persistent Hyaloid Artery,, 

The hyaloid artery, under normal circumstances, has 
quite disappeared before birth. In early foetal life it is 
continuous with the central artery of the retina, and runs 
forwards to the posterior flbro-vascular sheath of the lens/ 
which structure it supplies. 

It usually runs through as a single vessel, but it may 
divide into branches before reaching its destination. 
Occasionally it happens that the artery, or some portion 
of it, persists after birth, and can be seen with the 
ophthalmoscope; it may remain as a vessel containiug 
blood or as a small fibrous degenerated process running 
forwards for a greater or less extent into the vitreous. 

Its presence is sometimes associated with other con- 



V 

A 



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IN THE HOSPITAL MUSEUM. 541 

genital defects, and when persistent and patent it may 
run in a mass of fibrous tissue just behind the lens, which 
will probably be cataractous (Nos. 5 and 6). 

Description of Specimens. 

No. 1. — Series of six foetal eyes, ranging from the fourth to 
the ninth month. 

No. 2. — Dissection of an eye of a child who died, aged 3, 
as the result of a burn. 

There is congenital aniridia with anterior polar cataract. 
The cornea and sclerotic have been removed. 

The ciliary body is seen to end in a rudimentary iris ; this, 
however, was not made out to be present during life. 

On the front of the lens there is an anterior polar opacity, 
caused by a subcapsular proliferation of the lining epithelium. 

No. 3. — Dissection of an eye in which a small tag of 
pupillary runs across the pupil. It is so fine that it can hardly 
be seen without a lens. 

No. 4. — Iris and adjacent parts of the eye of an albino rabbit, 
in which there is a congenital coloboma of the iris. 

No. 5, — Portion of the eye of a child, aged 5 months, which 
was excised on account of its having the appearance of one in 
which a glioma was present. The lens was quite clear. It is 
now opaque. Behind the posterior capsule there is a dense 
white membrane (the posterior part of the fibrovascuJar sheath). 
Passing straight through the centre of the vitreous from th„ 
optic disc to the white membrane is a thin, thread-like band, 
which expands slightly when it arises from the disc; this is 
the persistent hyaloid artery. 

(In cases similar to this, but with the lens opaque, the dense 
membrane behind it would not be visible. If now the lens 
were broken up by needling, the membrane would appear after 
absorption had taken place ; this would be far too dense to 
needle, and if an attempt were made to withdraw it with capsule 
forceps, probably the greater part of the vitreous would come 
away with it.) 



e 



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542 DESCRIPTIVE CATALOGUE OF SPECIMENS 

]ST 0> 6.— Dissection of an eye, showing a persistent hyaloid 
artery. 

No. 7.— The posterior half of an albino rabbit's eye, showing- 
opaque nerve fibres, 

No. 8.— Eye of a child, aged 5, suffering from buphthalmos, 
which was excised on account of pain. T. + 2. The globe is 
enlarged in all directions, and the coats are very thin. The J 

cornea measures 15"5 mm. in its longest diameter, and 14'5 in ■ 

its shortest. The anterior chamber is very deep, and the lens, 
which was present and in situ, has been removed. 

The vitreous was more fluid than natural. 

The retina and choroid are greatly atrophied, but are not 
detached. The optic disc was deeply cupped, but is not seen 
in the mounted specimen. Microscopic examination showed 
that the angle of the anterior chamber was quite closed, through 
adhesion of the iris to the cornea at the periphery. 

No. 9 (4984).— Microphthalmia eye from a man, aged 28, 
which had been shrunken since birth. It has recently been pain- 
ful. The other eye is healthy. The eye measures 8 by 8 mm, In 
front was a small, clear cornea, of 3 mm. laterally, and behind 
the optic nerve was visible. Posteriorly was a cyst, measuring 
17 by 8 mm. On section the cornea was normal in thickness, 
the anterior chamber shallow ; iris and ciliary body present. 
The interior of the globe is almost entirely occupied by the 
lens, which measures 2 mm., and is calcareous. At the lower 
part behind the equator the sclerotic ends abruptly, and there 
is a gap reaching to the lower part of the optic nerve. To the 
point where the sclerotic is absent the cyst is attached; its 
outer wall is continuous with the sclerotic. Nearly all the 
retina is contained in the cyst. . 

(Reported in Trans. Ophth. Soc., vol. xvii, 1897.) 

]Sj- 0> 10.— Eye of a child, aged 14 weeks, which was much 
shrunken. A cyst-like space, containing retina and solid con- 
tents, was present, as in the last case, and in addition a plate 
of cartilage covered the front of the eye. 

(Reported in Trans. Ophth. Soc, vol. xvii, 1897.) 



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IN THE HOSPITAL MUSEUM. 



o43 



No, II.— Eye of a girl, aged 12, which had beer shrunken 
since birth. The eyeball is small, and there is a large cyst attached 
to it. The cornea is very thick, the cyst projects from the 
posterior part of the globe, and the sclerotic is continuous with 
this. There is a coloboma of the iris, and the lens is shrunken 
unci calcareous ; the cyst and vitreous are filled with folded 
membrane, and at the neck of the cyst there is some bone. 

(Reported in Trans. Ophth. Soc, vol. xvii, 1897.) 

Series VI. 
Myopia and Hypermetivpia. 

Eyes illustrating the changes in myopia or hyperme- 
tropia are very seldom obtainable for museum prepara- 
tions, unless they are affected by some disease which makes 
their removal necessary, consequently most of the speci- 
mens in this section exhibit other gross lesions. 

Hypermetropia produces but little change hi the eye, 
and this is entirely confined to the ciliary muscle, which 
is usually much hypertrophied. The antero-posterior dia- 
meter of the eye is shorter than in the emmetropic eye. 
It is also found that most eyes affected with primary 
glaucoma are hypermetropic. 

In myopia the changes in the anterior part of the eye 
are very slight. The ciliary muscle is usually much 
smaller than in emmetropia. The chief pathological 
changes occur in the posterior segment, and they are 
primarily the result of an elongation and stretching of 
the posterior pole of the eye. This stretching is most 
seen on the temporal side of the disc. The result is that 
the sclerotic, and with it the choroid, get pulled towards 
this side. As, however, the entrance of the optic nerve 
into the eye is a comparatively fixed point, the traction 
chiefly affects the surrounding parts, so that we find the 
sclera and choroid thinned and atrophied on the temporal 
side, and the choroid, drawn partly over the optic disc on 
the nasal side. 

This stretched area constitutes a posterior staphyloma, 
VOL* xiv, 2 x 



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514 DESCRIPTIVE CATALOGUE OF SPECIMENS 

and the sclerotic here is often extremely thin (Nos. 1, 2, 4, 
and 8). 

In addition to the thinning of the choroid and retina, 
inflammatory changes are likely to ensue, giving rise to 
patches of retino-choroiditis (No. 4). 

As the result of the abnormal conditions to which the 
eye is subjected, various other changes make their appear- 
ance. The vitreous may become separated from the retina 
at the posterior part (No. 3) ; degenerative changes may 
take place in it, which render it more or less fluid and 
opaque, and finally the retina may become detached, and 
this will render the eye hopelessly blind (Nos. 4 and 6). 

No. 1 (2165). — Section of tbe eye of a man, aged 25, who 
had a " cold " in it 10 years ago, but no injury. The eye is 
extremely myopic, its antero-posterior diameter being 38 mm., 
and its transverse 27 mm. The cornea and iris are adherent, 
and it has evidently undergone much inflammatory change. 
All the coats are greatly thinned, and the choroid is atrophied 
to a very marked degree, especially at its posterior part ; here 
there is an enormous posterior staphyloma. 

No. 2. — Section of an eye which shows numerous inflamma- 
tory changes in its anterior part. Its antero-posterior measure- 
ment is 31 mm. 

No. 3 (3425). — Extremely myopic eye, with posterior staphy- 
loma. The lens is now opaque, and the vitreous is degenerated. 
The retina and choroid are in situ, but there are numerous 
patches of retino-choroiditis ; the coats of the eye are much 
thinned. 

No. 4 (3696). — The eye was injured 56 years ago, and it had 
been defective since that time. It is extremely myopic, the 
antero-posterior diameter measuring 32"5 mm. 

The anterior chamber is deep, and the iris is covered with 
lymph. 

There is a very large posterior staphyloma. The choroid is 
greatly atrophied. The retina is entirely detached from the 
optic disc to the ora serrata. 



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IN THE HOSPITAL MUSEUM. 545 

ISTo. 5 (5070). — Section of a myopic eye which was also 
affected with a perforated nicer of the cornea. The iris is 
inflamed and atrophied. There are numerous patches of 
choroido-retinitis. There is a well-marked posterior staphy- 
loma, with a ring of atrophy around it. 

No. 6 (5292). — Myopic eye of a man which has been blind 
for 22 years; its antero-posterior diameter = 28*5 mm. 

The lens is absent, the retina detached, and the O.D. is 
cupped. 

No. 7 (5294). — Section of a degenerated myopic eye. 

The anterior chamber is deep, and the Jens was displaced 
into the vitreous, which is much shrunken. The retina and 
choroid are in situ. 

Series VII. 

Normal Series. 

No. 1. — Normal eye of a man who suffered from a sarcoma 
of the orbit, which necessitated the removal of the globe. The 
retina is now somewhat puckered, as the result of hardening 
asonfcs. 



2 N 2 



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516 



SUPPLEMENTARY CATALOGUE 



LIBRARY OF THE ROYAL LONDON OPHTHALMIC 
HOSPITAL, MOORFIELDS. 



Abnet, Captain W. de W. Colour Vision (Tyndall 

Lecture, 1894). 1895. 

Adams, Sir William. An exposure of the measures 
used by the Medical Officers of the London Eye 
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mia. (Vol. xii.) 1817. Pamphlets, vol. xii. 1817. 

Alexander. Neue Erfahrnngen uber leutische Augen- 

krankungen. Pamphlets, vol. xxiv, 1895, 

• Uber G-efassveranclerungen bei syphilitischen 

Augenkrankungen, 1895, 

Angelucci, Arnaldo. Untersuchungen liber die Sehtha- 
tigkeit der Netzliaut und des Geliirns. Pamph- 
lets, voL xxxi. 1890. 

Axenfeld and Uhthofp. See Uhthopp and Axenfeld. 

Axenfeld, Eick, and Uhthoff. Pathologic und patho- 
logische Anatomie des A,uges, 

Baker, A. H. Impaired Yision as tbe result of Sun- 
stroke. 1889. Functional Nervous Diseases of 
Reflex Origin. 1890. Infantile Cataract. 1892. 

All in vol. vii. 

Berger, EmiL Les Maladies des Yeux clans leurs rap- 
ports avec la Pathologie Generale. 1892, 

Bernheimer, Stefan, Uber die SehDerven-Wurzebi des 

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1893. 



SUPPLEMENTARY CATALOGUE OF THE LIBRARY. 547 

Berry, Geo. A. Ophthalmoscopic Diagnosis. 1891. 

Bird, John. Contributions to Social Pathology. The 

Blind and the Deaf and Dumb. (Vol. vii.) 1862. 

Bock, Emil. Zur Kenntniss cler gesunden und kranken 

Thranendriise. 1896. 

Anatomie des menschlichen Orbitalinhaltes nach 

Enucleation Angapfels. Pamphlets, vol. xxi. 1892. 

Die angeborenen Kolobome des Angapfels. Pam- 
phlets, vol. xxxii. 1893. 

Bossis, A. La Tuberculose de ITris. Pamphlets, vol. 
xxvii. 

Bowman, Sir W. Lectures on parts concerned in opera- 
tions on the Eye. 1849. 

Eranz Cornells Bonders. Pamphlets, vol. xi. 1891. 

Botce, Hubert. Text-book of Morbid Histology. 1892. 

Bruce, Alexander. Illustrations of the Mid- and Hind- 
Brain. 1892. 

Bull, Charles Stedman. Some unusual cases of Orbital 

Tumours. 1895. 

Chaffarp, Joseph. Contribution a l'etude des Yoies 

Lacrymales. 1889. 

Collins, E. Treacher. The Glands of the Ciliary Body. 

Pamphlets, vol. is. 1891. 

Pamphlet of Collected Works. 1895. 

Lectures on the Anatomy and Physiology of the 

Eye. Pamphlets, vol. ix. 1894. 
Researches into the Anatomy and Pathology of the 

Eye. 1896. 

Courtais, Eng. Maladies des Teux et Maladies des 

Dents. Pamphlets, vol. xxxiii. 1892. 

Curtis, John Harrison. A Treatise on the Physiology 

and Diseases of the Eye. 1835. 

Czermak, Wilhelm. Die Augenartzlichen Operationen. 1894. 

De Schwetnitz, G, E. Diseases of the Eye. 1892. 

Toxic Amblyopias. 1896, 

Deutschmann, R. Bei triage zur Angenheilknncle. Con- 
tinuous from Part I. 1890. 



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548 SUPPLEMENT ART CATALOGUE OF THE LIBRARY 

Dimmer, Frederick. Die ophtlialmoskopisclien Liehtre- 

flexe der Netzhaufc. 1891. 



Elze, K. Plasmodienbefunde bei Trachom. 1897. 
• Eversbusch, Oskar. Die neue Universitats-Heilanstalt 
fiir Augenkranke in Erlangen. Pamphlets, vol. 
sxxi. 1893. 
Die Pflege des Auges in Hans nnd Familie. 1893. 



Feilding, G. H. A new Membrane in the Eye. Pam- 
phlets, vol. vi. 1832. 

Fecer, 1ST. Die Beziehungen zwischen Zahn nnd Augen- 

affektionen. Pamphlets, vol. ix. 1893. 

Fick, A. Engen. Die Bestimninng des Brechzustandes 

eines Anges durch Schattenprobe. 1891. 

Lehrbuch der Angenheilkunde. 1894. 

Fick, Axenfeld, and Ubthoff. See Axenfeld. 

Fischer, R. Uber die Emboli e der Arteria Centralis 

Retinas. 1891. 



Foster, Michael. A Text-book of Physiology, 
Frost, W. Adams. The Fundus Oculi. 
Fuchs, Ernest. Manuel d'Ophtalmologie. 
■ Text-book of Ophthalmology. 



1892. 
1896. 
1892. 
1892 



Gayet, A. Elements d'Ophtalmologie : Lecons Clini- 

ques. 1893. 
Gondret, Lonis Francois. Treatise on treating Cerebro- 

sensorial Affections, Amaurosis, and Cataract. 1840. 

Gowers, Sir W. R. Diseases of the Nervous System. 1888. 

Graefe, Albreckt von. Three Memoirs on Iridectomy. 1859. 

Graefee, Alfred. Das Seben der Schielenclen. 1897. 

Greef, Richard. Die Retina der Wirbelthiere. 1894. 
Green, Edridge F. W. Colour Blindness and Colour 

Perception. 1891. 
Groenouw, Arthur. Anleitung zur Berechnung der 

Erwerbsfahigkeit bei Sehst drunken, 1896. 



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OF THE ROYAL LONDON OPHTHALMIC HOSPITAL. 549 

Haab, 0. Atlas der Ophthalmoskopie. 189o. 

Hamilton, D. J. A Text-book of Pathology. 1894. 

Hartridge and Macnamara. See Macnamara. 
Helmholtz. Beitrage zur Psycbologie und Physiologie 

der Sinnesorgane. Pamphlets, vol. xxxv. 1892. 

Herrnheiser-Prag, J. Die Refractionsentwicklung des 

mensehlichen Auges. Pamphlets, vol. xxx. 1892. 

Heeschbeeg. Funf unclzwanzigjahriger Bericht -Tiber die 

Augenheilanstalt. 1895. 
Einfuhrung in die Augenhcilkunde. Pamphlets, 

vol. xxxiv. 1892. 

Einfuhrung in die Augenheilkuude. 1892. 

Hertwig, Oscar. Lehrbnch der Eutwicklungsgeschichte 

des Menschen und Wirbekhiere. 1890. 

Holden, Ward A, An Outline of the Embryology of 

the Eye. 1893. 

Holthouse, Edwin. Convergent Strabismus and its 

Treatment. 1897. 

Hubert, Charles Francois. Etude sur le Developpement 

cle la Cornee et sur les Opacities Congenitales de 

cette Membrane. Pamphlets, vol. xxxviii. 1876. 

Hue, E. Essai sur les Tumeurs clu Nerf Optique. 18S2. 

Hutchinson, Jonathan. Descriptive Catalogue of the 

Clinical Museum. 



Jacobson, J. Graefes Yerdienste um die ISTeure Ophthal- 
mologic 1885, 

Jaeger, Edward, Juu. Beitrage zur Pathologie des 

Auges. 1870 

Jalabfrt, M. Catalogue General des Thesis d'Oculis- 

tique. Pamphlets, vol. xv. 1893. 

Jocqs, Bemy. Des Tumeurs clu ISTerf Optique. 1887. 

Kahlden, C. von. Methods of Pathological Histology. 

Translated by H. Morley Fletcher. 1894. 

Knies, Max. Die Beziehungen des Sehorgans and 
seiner Erkrankungen zu den lib ri gen Krank- 
heiten des Korpers und seiner Organe. 1893. 



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550 SUPPLEMENTARY CATALOGUE OF THE LTBRAUY 

Knies, Max. Relations of Diseases of the Eye to General 

Diseases. Translated by Henry D. Noyes. 1895. 

Konig, Arthur. Das Augenleuchten und die Erfmdung 

des Augenspiegels. 1893. 

Krienes, Hans. tTber Hemeralopie. 1896. 

Kundrat. Uber die angeborenen Cysten im unteren 

Augenlide, Mikrophthalmie und Anophthalmie. 

Pamphlets, vol. xi. 1880. 



Lagrange, Felix, fitudes sur les Tumeurs cle l'GEil, cle 

1'Orbite et des Annexes. 1893. 

Lang, William. The Methodical Examination of the 

Eye. 1895. 

Langer, E. Beitrag zur normalen Anatomie des men- 

schlichen Augen. 1891. 

Leber, Thecdor. Die Entstebung der Entziindung. 1891. 

Leclere, C. Des Opacites congenitales de la Cornee. 1880. 

Lee, Arthur B. The Microtomist's Yade Mecum. 1893. 

Lefert, Paul. La Practique des Maladies des Teux 

dans les Hopitaux de Paris. 1893. 

Lloyd- Owen, D. C. The Elements of Ophthalmic Thera- 
peutics. 1890. 



Macnamara, C. N., and Hartrjdge, G. Diseases and Re- 
fraction of the Eye. 1891. 

Magnus, Hugo. Augenarztliche Unterrichtstafeln. 10 

Parts. 1892-95. 

Martin, Werner. Beitrag zur Prognostik der Uveal- 

sarcome. 1885. 

Masse, E. Kystes, Tumeurs Perlees, et Tumeurs Der- 

mo'ides de Plris. 1885. 

Mauthner, Ludwig. Lehrbuch der Ophthalmoscopic 1868. 

Earbenlehre. Pamphlets, vol. xxxi. 1884. 

Secundar-glaucom und Glaucom-theorien. Pam- 
phlets, vol. xxxi. 1893. 

Maxwell, Theodore. Terminologia Medica Polyglotta. 

Miroyitch. De Pinnuence de la Veloeipeclie snr la 

Vision. 1897. 



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OF THE ROYAL LONDON OPHTHALMIC HOSPITAL. 551 

Neale, Richard. The Medical Digest Appendix. 1891-95. 

Nettleshlp, Edward. Student's Guide to Diseases of 

the Eye. 6th Ed. 1897. 

Nicolin, Jules. Du Coloborne congenital des Paupieres. 

Pamphlets, vol. xxxviii. 1888. 

Norris, W. F., and Oliver, C. A. A Text-book of Oph- 
thalmology. 1894. 

System of Diseases of the Eye. (Yols. i and 

ii.) ^ 1897. 



Ohlemann. Die Farbenblindheit und ihre Diagnose. 1897. 

Owen, Lloyd. See Lloyd- Owen. 

Oculist, experienced. The art of Preserving the Sight 

unimpaired to an Extreme Old Age. 1813. 

(Author's name not given.) 
Oeller, J., and Knapp, A. EL Atlas of Ophthalmology. 

Parts I, II, and III, 1896-97. 

Oliver, C. A. Cases of symmetrically placed Opacities 

of the Cornea. 1892. 

Oliver and Norris. See Norris. 
Otto, Reinhard. Untersuchnngen liber Sehnerwen- 

veranderungen bei Arteriosclerose. Pamphlets, 

vol. xxiv. 1898. 



Panas, P. Traite des Maladies des Yeux. ("Vols, i and 

"•) 1894. 

Pansier, P. Traite d'Electrotherapie Oculaire. 1896. 

Phillips, R. J. Spectacles and Eyeglasses. 189- . 

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dies congenitales du Globe de 3'(Eih 1886. 

Pope, T. H. Cataract in the Madras Presidency of 

Southern India. Pamphlets, vol. xli, 1896, 

Prince, A. E. The Pully Method of Advancing the 

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In Memoria cli Antonio Qnaglino. 



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DO -2 SUPPLEMENTARY CATALOGUE OF THE LIBRARY 

Reports of the New York Eye and Ear Infirmary. 1894. 

Rochon-D uorgneaud. Precis Iconograpkique d Amatomie 

normal e de 1'CEil. 1895. 

Roosa, St. John. • Constitutional Conditions combined 

with Ametropia. The cause of Asthenopia. 

Pamphlets, vol. vii. . 1891. 

Rutherford, William. Outlines of Practical Histology. 1876. 



Satler, EL Die Trachoinbehandlang einst und jetzt. 

- Pamphlets, vol. xviii. 1891. 

Schen'k, S. L. Elements of Bacteriology, Translated 

by W. R. Dawson. 1893, 

Schiess, H. Kurzer Leitfaden der Refractions und Ac- 
commodations -Anom alien. 1893. 

Schoen, W. Die Euncuonskrankkeiten des Auges. 1895. 

Des geschichtliche Entwicklung unserer Kenntniss 

der Staarkrankkeit. 1897, 

Schulek, Wilhelm. Ungarische Beitrage zur Augenheil- 

kunde. " 1895. 

Schultze, Max. Observationes cle Retinae Structura 

Penitiori. 1889. 

Schwarz, Otto. Die Bedeutung der Augenstoruugen. 1898. 

Schweigger, C. Handbuch der Augenheilkunde. 6th 

Ed. ' - 1893. 

Smith, Priestly. On the Pathology and Treatment of 

Glaucoma. 1891. 

Snell, Simeon. Miner's Nystagmus. 1892. 

Squirr, Peter, The Pharmacopceias of the London 

Hospitals. 6th Ed. 1891. 

Steiger, Adolf. Beitrage der Hornhautrefraction. Pam- 
phlets, vol. xxxii. 1894. 

Stephenson, Sydney. Epidemic Ophthalmia.. 1895. 

Ophthalmic Nursing. 1894. 

Sternberg, George M. A Text-book of Bacteriology. 1896. 

Stoewer, P. Anleitung zur Brillen~verordnung\ 1895. 

SiLiAUB, M. Die Behandiung der Hornhaut-Entzundung. 

(July No. of Berliner Klinik.) 1896. 

Sutton, Julm Bland. Tumours Innocent and Malignant. 1894 



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1893. 



OF THE ROYAL LONDON OPHTHALMIC noSPITAL. O5o 

Swanzy, H. R. Handbook of Diseases of the- Eye. 4th, 

5th, and 6th Ed. 1892-97. 

Tweedy, John. Lecture on the ^Etiology of Constitu- 
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In Memoriam, Thomas Wharton Jones. Pamphlets, 

vol. ix. 1891. 

Uhthoff and Axenfell. Beitrage zur pathologischen 
Anatomie unci Bakteriologie eiterigen der Kera- 
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Uhthoff, Axenfeld, and Fick. See Axenfeld. 

Yale, Francis. Lectures on the Errors of Refraction. 1893. 
Yianna, J. cle Mello. Recherches Cliniques sur les 

Paralyses cles Muscles de l'CEil. Pamphlets, vol. 

xxxiii. 
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Graneuleuse. 1896. 

Vossius, Adolf. Sammlung zwangloser Abhandlungen 

der Augenheilkunde. Band I, &c. 

Wagner, Carl. tJber metastatische Aderhauttumoren. 1891. 
Wallace, James. The Physical and Physiological Bases 

of Colour Vision. Pamphlets, vol. xi. 1894. 

Ware, James. Chirurgical Observations relative to the 

Eye. 1805. 

Watson, W. Spencer. The Lacrymal Passages. 1892. 

Wecker, L. de. Reminiscences Historiqn.es concernant 

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ix and xli. 1893. 

Weinland, Ernst Freclerich. rJeue Untersuchuugen iiber 

die Funktionen der Netzhaut. 1895. 

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xxxis. 1818. 



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551 SUPPLEMENTARY CATALOGUE OF THE LIBRARY. 

Wickerktewicz, B. Elfter Jahres-Bericht iiber die Wirk- 
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Quelcpies mots sur l'operation de la Cataract secon- 
dare. Pamphlets, vol. xli. 1895. 

Widmark, Johan. Beitrage znr Ophthalmologic. 189.1. 

Wilbrand, H. Die hemianopischen Gesichtsfeld-Formen 
und das optische Wahrnehmungszentrum. Pam- 
phlets, vol. xvi. 1890. 

Wintersteiner, Hugo. Das Neuroepithelioma Retinae. 1897. 

Zenker, Heinrich. Tausend Staaroperationen. Pam- 
phlets, vol. xli. 1895. 
Ziegler, a Text-book of Special Pathological Anatomy. 1897. 
Zoth, Oskar. Die Wirkungen der Augemxmskeln. 1897. 



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INDEX OF AUTHORS TO VOL. XIV. 



TAGE 

Atwool, W. Tilling-hast. 

Two cases of hereditary congenital night blindness . « 260 

Collins, E. Treacher. 

Case of permanent central scotoma caused by looking at the 

sun, with partial atrophy of the optic nerve 374 

Descriptive catalogue of specimens in the hospital museum . , 1 

The development of the posterior elastic lamina of the cornea 

or membrane of Desceniet , 305 

Fischer, E. Cotton, and Marshall, C. Deyeeeex. 

The operative treatment of lamellar cataract 478 

Eisher, J. Herbert. 

Concomitant strabismus. The accessory adductors and abduc- 
tors 448 

A case of subhyaloicl haemorrhage, in which the specimen was 

obtained for microscopic sections . . 291 

Hallidie, Andrew. 

. Topography of the emmetropic fundus 361 

Lawson, Arnold. 

Bacteriological history of trachoma, with personal observations 

on 15 cases 484 

McKenzie, EL Y. 

On the results obtained after the extraction of foreign bodies 

from the eye with the electro-magnet .♦.,,.... 274 

McKenzie, H. V., and Marshall C. Deyereux. 

On Ophthalmia Neonatorum. 410 

Marshall, C. Devereex. 

Descriptive catalogue of specimens in the hospital museum (con- 

tinned?) 500 

Metastatic carcinoma of the eyeball. . , 415 

On meningitis following excision of the eyeball for panophthal- 
mitis , 312 

On the immediate and remote results of cataract extraction ... BG 
On the pathological examination of the eyeball , , 37? 



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556 INDEX OF AUTHORS. 

Marshall, C. Deyereux. 

Notes on glioma retinae 455 

Supplementary catalogue of the library of the K.L.O.H., Moor- 

fi elcls 547 

Marshall, C. Deyereux and Fischer E. Cotton. See Fischer. 
Marshall, 0. Deyereux and McEenzie, H. V. See McKenzie. 

Eidley, N. C. 

Notes on a case of thrombosis of the central artery of the 

retina with acute glaucoma as a sequel 264 

Serous cyelitis , 237 

Spicer, W. T. Holmes. 

Contracture and other conditions following paralysis of ocular 

muscles , 220 

Striated opacity of the cornea , 338 

Thompson, A. H. 

Tobacco amblyopia 405 



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INDEX OF SUBJECTS TO VOL. XIV. 



PAG-E 

Amblyopia, tobacco 4D° 

Carcinoma, metastatic, of the eyeball 41 o 

Catalogue, descriptive, of specimens in Hospital Museum {continued).. 1 

Catalogue, supplementary, of the library. ...... 547 

Cataract extractions, result of - 56 

Cataract, lamellar, operative treatment of 478 

Central permanent scotoma caused by looting at the sun f ... 374 

Contracture and other conditions following paralysis of ocular muscles 220 

Cornea, development of posterior elastic lamina 305 

Cornea, striated opacity of the , 338 

Cyclitis, serous.. , 237 

Emmetropic fundus, topography of , 361 

Glioma retinae, notes on 456 

Magnet extraction of foreign bodies from the eye, results obtained 

after . . 274 

Meningitis following excision of the eyeball for panophthalmitis 312 

Night blindness, two cases of hereditary 260 

Ophthalmia neonatorum 410 

Pathological examination of the eyeball c 379 

Strabismus, concomitant : The accessory adductors and abductors .... 448 

Subhyaloid hemorrhage, a case of 291 

Thrombosis of the central artery of the retina, notes on a case of 264 

Trachoma, bacteriological history of 4S4 



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OPHTHALMIC HOSPITAL 
E1POBTS. 

-\ ." . -■ -_ "'Edited by 

." :.-> WILLIAM LANG, F.R.C.S., Eng, *- ' " % 



"it* t\ Duvbbeux MAuSHAit', Metastatic Carcinoma of the Eyeball .*..*! 415 

• 18, "J. ifxBBSfi3? Fishek, Concomitant Strabismus : The Accessory Ad- 
ductors and Abductors ;, .♦..;.,...,»....«..... . . « . 448 

19.-0* Detebbtjx^ MAESHAiiiij Kbtes on Glioma Retiree . «\ /,.... . . . ■, 4M 

20. E. C. Fischee and C. Deyerepx M ar'sha&l, The Operative Treat* • ■ ■ 

' ment of- Lamellar Cataract *,»..* .*,...>....,. ' . 4v 8 : 

21. Arnold ' " -Historical -ReYietr and Criticism of the Bsete- 

of Trachoma^ .with Personal Observations on 

...., .".-... ...-.-!-.. ..:/.. ..»..'. ,... :... 48 1 

22. <X Dbtsrefx Maesiiai,l, ( Inscriptive Catalogue- of Specimens in the . ■ ' 

Hospital Museum (continued) ,~. ,...».,,.,, 500 

23. /Supplementary Catalogue of the library of the Royal London Oph- 

, . ' / tltalmic Hospital, Moorfields >X, . • ^ . .V. .,,,., ; * 540 

Index to Volume' XI V (Authors). .............................. 555 

' •• » ' '» (Subjects) ............ ......... ..,...". 557 



t. Amy A. CHURCHILL, 7, GREAT MARLBOROUGH STREKT. 



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